RIBAL ASTHMA SURVEY PROJECT (TASP) FINAL EPORT · AIAN children are 1.82 times more likely to have asthma than White children (95% confidence interval [CI]: 1.33, 2.49) 7. AIAN children

TRIBAL ASTHMA SURVEY PROJECT (TASP) FINAL REPORT

Prepared for: California Breathing Asthma Program

Environmental Health Investigations Branch California Department of Public Health (CDPH)

Richmond, California

Prepared by: Rebecca Garrow, MPH and Kristal Chichlowska, PhD, MPH

California Tribal Epidemiology Center (CTEC) Sacramento, California

TABLE OF CONTENTS ACKNOWLEDGEMENTS .................................................................................................................................. 1

ABSTRACT ................................................................................................................................................... 2

INTRODUCTION ............................................................................................................................................ 4

METHODS ................................................................................................................................................... 6

RESULTS ................................................................................................................................................... 11

Characteristics of the TASP Sample .................................................................................................................................. 13

Level of Concern for Potential Allergens in the Home ...................................................................................................... 23

Asthma Status ................................................................................................................................................................... 25

Asthma Co‐Morbidities ..................................................................................................................................................... 27

Asthma Status and Housing Conditions ............................................................................................................................ 30

Level of Concern for Home Air Contaminants by Asthma Status ..................................................................................... 38

Pediatric Asthma ............................................................................................................................................................... 39

Public Housing ................................................................................................................................................................... 40

Renters .............................................................................................................................................................................. 48

Multivariable Analysis ....................................................................................................................................................... 50

DISCUSSION .............................................................................................................................................. 53

REFERENCES .............................................................................................................................................. 56

APPENDIX A: SURVEY QUESTION SOURCES ...................................................................................................... 58

APPENDIX B: THE BORDER ASTHMA AND ALLERGIES STUDY (BASTA) .................................................................. 59

APPENDIX C: SURVEY INSTRUMENT ............................................................................................................... 64

APPENDIX D: INFORMED CONSENT .............................................................................................................. 113

APPENDIX E: HEALTH EDUCATION MATERIALS ............................................................................................... 116

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ACKNOWLEDGEMENTS

The Tribal Asthma Survey Project (TASP) would like to acknowledge Jared Dunlap of the Fon‐du‐Lac Band of Minnesota Chippewa for his assistance with data entry and survey dissemination; Karen Santana of the Manchester Point Arena Band of Pomo Indians for her assistance with survey dissemination; and, Renee Bowden of the Big Valley Rancheria Band of Pomo Indians for travel coordination and incentive purchase reimbursements. Their efforts and enthusiasm were invaluable to the overall success of the project. TASP would also like to thank Liza Lutzker, MPH, Epidemiologist for the California Breathing Program, for her assistance with the survey design and development, her assistance in the development of health education materials, and the technical support she provided to the project throughout the funding period. TASP would like to acknowledge Satoka Barnett of the Muscogee Creek, Bettina Bergen of the Lower Brule Sioux Tribe, and Cheryl Wilson of the Metlakatla Indian Community for pilot‐testing the original survey instrument and for providing open, honest feedback about the survey questions, design, and delivery. The many employees of the California Rural Indian Health Board (CRIHB) who took the time to give feedback on the survey tool are also deserving of our thanks. Finally, TASP would like to thank all the American Indian and Alaska Native people who participated in TASP by completing a survey. Their answers will help the California Tribal Epidemiology Center and California Breathing better understand the housing conditions and asthma status of Native people in California. Their participation has been invaluable, and we give our deepest thanks and gratitude for the time they took to complete the survey and represent the California Native community.

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ABSTRACT

Nationally, asthma disproportionately affects American Indians and Alaska Natives (AIANs), where prevalence estimates are 25% higher than White persons1. There are very few studies documenting the prevalence of asthma in California AIANs. According to the California Health Interview Survey (CHIS) and the California Behavioral Risk Factor Surveillance System (BRFSS) survey, AIANs have the highest prevalence of asthma of the major race/ethnicity groups in California. However, CHIS and the BRFSS are limited in that they are both telephone surveys, do not oversample the AIAN population, and are often not representative of the rural AIAN population in California. Nonetheless, the high potential prevalence of asthma and potential exposure to harmful allergens in the home environment represents one causal pathway by which AIANs experience greater asthma when compared to Whites. The California Tribal Epidemiology Center in collaboration with the California Department of Public Health (CDPH), Environmental Health Investigations Branch, California Breathing implemented the comprehensive Tribal Asthma Survey Project (TASP). This survey gathered asthma and housing condition‐specific data presented in this report, which can empower tribes to determine program priorities, direct program planning, develop new policies and culturally appropriate intervention strategies. The specific aims of this study were to:

1) Determine the prevalence of self‐reported asthma in AIANs in California; and 2) Examine the association between housing conditions and asthma in California AIANs.

Participants were recruited from Indian events such as Pow‐Wows, Big Times, health fairs, and community gatherings throughout California over a 7‐month period, between October 2009 and May 2010. There were a total of 610 surveys collected. The majority of the sample was female (65%) and lived in California (94%). The mean age was 42.4 years (standard deviation (SD): 15.6), the mean Body Mass Index (BMI) was 32.0 (SD: 7.4), and 57% reported they had greater than a high school education. Over half of the sample (55%) reported they lived in a one‐family house. Twenty‐one percent (n=131) of the sample had been diagnosed by a doctor or other health professional with asthma. Of those diagnosed with asthma, the sample was 76% female with a mean age of 44.6 years (SD: 15.5). The prevalence of asthma was 14.3% for males and 25.3% for females. Of those who had been diagnosed with asthma (n=131), 76% still had asthma. The mean age of diagnosis was 27.1 years (SD: 17.9). Almost half (49%) reported that their asthma had been made worse by workplace conditions. In the past 30 days, the average number of days that respondents reported they had symptoms of asthma (which was defined as coughing, wheezing, shortness of breath, chest tightness, or phlegm production when you do not have a cold or respiratory infection) was 9.1 (SD: 10.2). Among females, the prevalence of asthma was 1.67 (Confidence Interval (CI): 1.16, 2.40) times as high in those with pets with fur or feathers in the home in the past 6 months compared to those without pets with fur or feathers. The prevalences of asthma in women were also higher in those who have seen mold greater than the size of a dollar bill (Prevalence Ratio (PR): 1.84, CI: 1.28, 2.65) and have smelled a moldy or musty odor (PR: 1.54, CI: 1.07, 2.21) in their home in the past 30 days compared to those who have not seen or smelled mold in their home. As a result, educational efforts on controlling mold in the home may be beneficial to this community. Among men, there were no associations between potential allergens in housing and asthma status. No statistically significant associations between socioeconomic status and asthma were observed in both men and women.

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We additionally included information on pediatric asthma and asthma morbidity in the TASP survey. The prevalence of asthma in children under the age of 18 living in a survey participant’s home was 21%. Of children who had been diagnosed with asthma, 79% still had asthma. In the past 12 months, 71% of children diagnosed with asthma had symptoms, taken medication, or seen a doctor for their asthma. Among adults who were told by a doctor or other health professional that they had asthma (n=131), 17% had missed at least 1 day of school or work in the past 12 months due to asthma. Almost 23% had visited the emergency room at least once in the past 12 months for asthma‐related reasons. Furthermore, in the TASP population 72% of those with doctor‐diagnosed asthma reported that their usual activities had been limited due to asthma in the past 12 months. The loss of productivity in the workplace as well as preventable hospitalizations due to asthma deserve further research to accurately estimate the true “cost” of asthma in California AIAN. Limitations of the study included its convenience sampling method, the timeline of the grant failing to overlap with the season that AIAN cultural events occur, and not verifying Indian heritage. Strengths include its popularity due to word‐of‐mouth, the receptiveness of the health education materials and incentives provided, and the enthusiasm of participants wanting to share personal stories about asthma and learn more about asthma management after completion of the survey. Strengths included the $15 gift cards, which proved to be a strong incentive for event attendees to participate in the TASP study – due to both word‐of‐mouth and visible signage. Word‐of‐mouth was a key component in recruiting survey participants. Upon completion of the survey, several people informed their respective networks of the survey and incentive opportunity. A majority of participants were recruited in this manner. While the TASP study had participants from several counties throughout California with high proportions of AIAN populations, and included both rural and urban AIAN, it may not represent the exceptionally diverse AIAN population in California. More research is needed on the prevalence of asthma, asthma morbidity and housing conditions in California AIANs.

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INTRODUCTION

The Epidemiology of Asthma Asthma, a chronic disorder of the airways that is characterized by recurring respiratory symptoms, variable airflow obstruction, airway hyperresponsiveness, and underlying inflammation 2, has been on the rise in recent decades worldwide, especially among children 3. In the United States from 1980 to 1995 the prevalence of asthma among children 0‐17 years of age increased from 3.6% to 7.5%. In 2005, 8.9% of children were reported to have current asthma, which would total 6.5 million American children 4, while 7.7% (22.2 million) of adults were currently suffering from asthma 1. In California, 5 million have been diagnosed with asthma and almost 3 million suffer from current asthma 5. Compared to the U.S. population overall, lifetime prevalence increased 80% from 1984 to 2005 (7.6% to 13.7%) in California residents 5. Nationally, asthma disproportionately affects American Indians and Alaska Natives (AIANs), where prevalence estimates are 25% higher than White persons 1. The percentage of AIAN adults 18 years of age and older with asthma was 14.2% (SE 1.66), compared to 11.65% for Whites6. Percentages differed by gender – with 18.2% of AIAN females and 10.1% of AIAN males having asthma, compared to 13.0% and 10.1% of Whites, respectively. The prevalence of asthma in California AIANs was 9.2% compared to 7.4% in Whites 5. AIANs also have higher rates of lifetime asthma diagnoses than Whites, 12.1% and 10.9%, respectively. Among AIAN children, asthma prevalence, morbidity and mortality are higher compared to white children. For example, from 2001 to 2005, 9.2% of all children aged 2 to 17 years had asthma; 13% of AIAN children and 8.4% white children 7. In fact, AIAN children are 1.82 times more likely to have asthma than White children (95% confidence interval [CI]: 1.33, 2.49) 7. AIAN children also have the highest prevalence of asthma attacks; 67.3%, compared to 61.3% for whites and 60.7% for all U.S. children 7. In Washington State, asthma hospitalization rates from 1987 to 1996 for children aged 0 to 17 years were similar for all children and AIANs, whereas 50% of AIAN children had multiple hospitalizations compared to 42% of all children 8. There are very few studies documenting the prevalence of asthma in California AIANs. According to the California Health Interview Survey (CHIS) and the California Behavioral Risk Factor Surveillance System (BRFSS) survey, AIANs have the highest prevalence of asthma of the major race/ethnicity groups in California. In 2003, CHIS reported 8% of Californian adults and children had active asthma, and the highest prevalence of active asthma in California was seen in AIAN: 17% for children and 13% for adults 9. CHIS data for 2007 reported that 22.2% of AIAN reported a diagnosis of asthma, compared to 14.8% of non‐Hispanic Whites, and 13.6% for all races. The California BRFSS data from 2005 reported that 13.5% of AIAN‐only were ever told they had asthma, compared to 14.0% for Black‐only, 12.8% for White‐only, and 13.2% for all race/ethnicities total. However, CHIS and the BRFSS are limited in that they are both telephone surveys, do not oversample the AIAN population, and are often not representative of the rural AIAN population in California. Housing Conditions as Potential Determinants of Asthma Asthma is a multifactorial disease that has been associated with genetic, environmental, race/ethnicity, poverty, urbanization, psychosocial, and infectious factors 10. Although, several risk factors are likely to be important determinants of asthma, the large health differences among lower‐income and minority families compared with other populations suggest housing conditions may contribute to asthma in some populations. For example, asthma rates are higher among children living in low‐income communities 11. From 2001 to 2004, asthma in children living below the federal poverty level was 10.3%, compared with 6.4–7.9% for those at or above the poverty level 12. In light of this research, it is possible that the condition of an individual’s home may serve as a marker for some important underlying factors that trigger asthma beyond those of psychosocial and heredity.

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Exposure to numerous allergens is common in U.S. homes. In a study using a housing environmental index survey, 82% of participants had at least one allergen risk indicator present. Risk indicators included humidity, temperature, carbon dioxide, formaldehyde, nitrogen dioxide, allergens and the occurrence of tobacco smoke and pets 13. The National Survey of Lead and Allergens in Housing (NSLAH) found that 51.5% of surveyed homes had at least 6 detectable allergenic risk factors. In addition, race/ethnicity, income, housing type, absence of children, and presence of smokers, pets, cockroaches, rodents, and mold and moisture problems were independently associated with higher allergen levels 14. Structural damage in housing facilitates the entry of cockroaches and rodents into living spaces, and water leaks trap moisture within the home, thereby supporting the growth of molds and bacteria. Furthermore, in a study of almost 1,000 homes in Connecticut and Massachusetts, low income and living in a multifamily home in a high population density area with a higher occupancy rate per room were associated with higher cockroach allergens 15. Home overcrowding can aggravate asthma conditions by making disease transmission easier and an increase in allergy levels (such as dust, smoke, dander and other contaminants). It is estimated that in tribal areas, 28% of AIAN households are overcrowded, compared to 15% of all AIAN households and a national average of just 5% 16. A national survey of tribal housing estimates that the true overcrowding proportion is even higher ‐ almost 40%. According to the US Census, a home is defined as overcrowded if there are 1.01 or more persons per room. According to the 2000 Census, California has more AIAN than any other state,17 with 627,562 (1.9%) people self‐identified as AIAN in combination with one or more races, and 333,346 (1.0%) people self‐identified as being only AIAN.17 The Bureau of Indian Affairs has certified 107 federally recognized tribes, Rancherias and federations in CA.18 AIANs in CA have a median household income of $38,764 compared to $53,734 for non‐Hispanic whites. Nearly a third of the AIAN adult population 25 years of age and older (32%) did not have a high school diploma compared to 11% of non‐Hispanic whites.17 Such disparate conditions may contribute to housing conditions, and in turn asthma and asthma morbidity. To date, there are very few epidemiological studies on housing conditions and asthma correlates in AIAN. An increased (albeit non‐significant) risk for asthma was seen in AIAN children in New York when smoking occurred in the home in the past 12 months (odds ratio [OR]=1.49), where burn‐barrels were within a five‐minute walk from the home (Odds Ratio (OR)=1.56) and where the garage was attached to the home (OR=1.31) 19. In summary, the high prevalence of asthma and potential exposure to harmful allergens in the home environment represents one causal pathway by which AIANs experience greater asthma compared to Whites. In order to investigate this, the California Tribal Epidemiology Center in collaboration with the California Department of Public Health (CDPH), Environmental Health Investigations Branch, California Breathing implemented the comprehensive Tribal Asthma Survey Project (TASP). The specific aims of this study were to: 1. Determine the prevalence of self‐reported asthma in AIANs in California; and 2. Examine the association between housing conditions and asthma in California AIANs.

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METHODS

Background Data were collected as part of TASP: Tribal Asthma Survey Project, a statewide cross‐sectional survey to examine the prevalence of asthma and correlates of asthma morbidity and related housing conditions for AIANs in California. The project was approved by the California Rural Indian Health Board (CRIHB) Executive Committee on August 9th, 2009 via teleconference. Approval for this project was granted by the California Rural Indian Health Board’s Institutional Review Board on October 15, 2009, prior to initiating interviewing activities. Survey Population Men and women aged 18 years and older who self‐identified as AIAN were eligible to participate in TASP. Specifically, participants were asked to verbally answer ‘Yes’ or ‘No’ when the survey administrator asked if they were American Indian or Alaska Native and if they were at least 18 years of age. Later, in an attempt to identify participants who had already completed a survey, an intake question was added that asked if the participant had received a $15 gift card from CTEC or taken the Tribal Asthma Survey at another event in the last 12 months. Participants were excluded if they indicated their race was not AIAN, they were not 18 years of age, or if they had taken the Tribal Asthma Survey at another location or previous event. Data Collection Instruments and Procedures Survey Sites and Participants Initially, data collection was to occur at Tribal Clinics throughout California. However, after further research it was decided that traveling to Tribal Health Programs and Clinics throughout California would not warrant a large enough sample size in such a short time frame, as the number of patients seen per day, per clinic, can be very low. Furthermore, to obtain sufficient geographic representation, multiple clinics would have to be visited for several days at a time. Instead, participants were recruited from Indian events such as Pow‐Wows, Big Times, health fairs, and community gatherings throughout California over a seven‐month period, from October 2009 through May 2010. This allowed for greater geographic representation (see Figures 1 and 2) in a shorter time frame.

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TASP Data Collection Events (October 2009 to May 2010)Event Location Date Surveys

California Annual Tribal Leaders Consultation Conference on the Morongo Reservation Morongo, CA Tuesday 3/8/10 ‐

Thursday 3/10/10 76

California Rural Indian Health Board’s Annual Board Meeting Reno, NV Thursday 10/15/09 ‐

Saturday10/17/09 58

California State University Fresno Pow‐Wow Fresno, CA Saturday 4/10/10 41 California State University Humboldt Big Time Arcata, CA Saturday 4/10/10 82

California State University Long Beach Pow‐Wow Long Beach, CA Saturday 3/13/10 99

Georgetown Nature Fest Georgetown, CA Saturday 4/24/2010 2

Manchester‐Point Arena Band of Pomo Indians Tribal Election Meeting Point Arena, CA Saturday 11/14/09 101

Riverside‐San Bernadino Indian Health Center’s Health Fair on the Soboba Reservation Hemet, CA Saturday 5/1/10 38

Sacramento Native American Health Center’s Winter Banquet Sacramento, CA Saturday 12/12/09 64

Tule River Tribe’s Health Fair on the Tule River Reservation Porterville, CA Friday 4/2/10 49

Survey Instrument The survey instrument was created in collaboration with the CDPH California Breathing staff. Survey questions were derived from previously developed questionnaires used in research in Indian country, or developed and tested for Asthma or housing issues. Survey topics included asthma and asthma symptoms for adults and children in the home, allergens in housing, demographic variables, health conditions, and perceptions of home and community health environments. All questions included on the final instrument were pulled from the following survey instruments:

• Tribal Behavioral Risk Factor Surveillance Survey; • California Behavioral Risk Factor Surveillance Survey; • Behavioral Risk Factor Surveillance Survey Asthma Call‐Back Survey; • National Survey on Lead Hazards and Housing Allergens; and • Border Allergies and Asthma Study (BASTA).

A detailed explanation of questionnaires, questions used, and modifications made, if any, can be found in Appendix A. A more robust explanation of the BASTA study can be found in Appendix B. The survey was pilot‐tested with three AIAN employees at the California Rural Indian Health Board. Although both self‐administered and oral‐administered surveys were initially created, the pilot‐tested survey was administered orally, and elimination and modifications were made to several questions, including grammar, order, and response options. The initial survey was also piloted at the first cultural event in October 2009 at the CRIHB Annual Board Meeting. While one‐on‐one interviews were preferred to administer the survey and collect response data, due to staff and time limitations, in‐person interviewers were deemed unfeasible. Thus in order to maximize participation, and since only 2 staff members were available to administer surveys per event, surveys were self‐administered, rather than orally administered by an interviewer. Only self‐

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administered versions of the survey were distributed at remaining data collection sites. Questions that had a high mis‐response rate were re‐worded, and skip patterns were confined to one page when possible. All questions except for one were able to be modified so that they could be combined or were consistent with the final draft of the survey. The final version of the TASP survey was 25 double‐sided pages, consisted of 97 questions and 16 skip patterns, and can be found in Appendix C. The survey instrument was completely anonymous – names or any other personally identifiable information were not included. Most participants were able to complete the survey in about 20 minutes. Survey Administration Events were chosen according to the likelihood of AIAN populations at the events, the timeline, the geography, and the feasibility of the survey being administered at such an event. Two events were not attended because event organizers deemed a survey would not be appropriate. Other events were either too close in proximity to each other and overlap of participants was likely (i.e., the California State University Long Beach (CSULB) Pow‐Wow and the University of California, Los Angeles (UCLA) Pow‐Wow), or did not occur during the project time frame. Numerous AIAN‐specific events occur in the months between June and October, however, the funding period was from October to June. As a result, several events were not attended. Surveys were administered in teams of 2 people at 9 of the 10 events; at one event only 1 research staff was needed to administer surveys. At the first two data collection events, Informed Consent was obtained (see Appendix D for Informed Consent document) after an overview of the survey and its purpose were provided. Although the Informed Consent process did not appear to deter participation in TASP, we altered protocol after the Manchester‐Point Arena Tribal Elections Meeting by spending more time to explain the importance of the survey to California Indians and representativeness of the respondent to their local tribe/tribal community. At all remaining events, the project coordinator or research assistant went through the Informed Consent document in detail with each participant, explaining the survey purpose, procedures and benefits, confidentiality, rights as a volunteer, and the volunteer agreement sections. Signs were posted at the survey table, which stated that AIAN participants over the age of 18 could receive a gift card for $15 for completing a survey. Additional protocol modifications to the survey administration were implemented after it was determined that a high proportion of respondents listed “I Don’t Know” as responses to the majority of the questions in the survey, and several respondents followed skip patterns incorrectly at the second event in Point Arena, CA. Protocol was altered to explain skip patterns and to show examples to each participant to increase the likelihood that skip patterns would be adhered to appropriately. These protocol changes in the delivery of the survey and explanation of the informed consent document were successful in increasing the number of correctly filled out surveys at the remaining 9 events. Participants were told that by turning in a completed survey, they would receive a gift card in the amount of $15 for either Target, Safeway, Vons Grocery Stores, or Shell Gas Station. After a participant completed their respective survey, it was given to TASP staff who then briefly checked the survey for completeness. Participants completed their surveys in different settings, depending on the type of event. At conferences and meetings, participants were permitted to take their survey into breakout session rooms. During Pow‐Wow’s, Big Times, and Health Fairs, tables and chairs were provided behind the project staff for participants to take

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the survey. Seven events occurred exclusively on the weekends, and two included at least one weekday and one weekend. Health Education Materials Six free health education materials on asthma were available to all TASP participants and event attendees. Two of the health education materials [Myths about Asthma and Guidelines for an Asthma Friendly Home] were from the California Department of Public Health, and were adapted aesthetically and content‐wise to be culturally‐competent and Indian‐specific. Three of the health education materials were provided by Blue Shield of California [Asthma Home Checklist, Your Asthma Action Plan, and Living With Asthma – A DVD], and one was provided from the Minnesota Department of Public Health [Asthma Triggers]. All health education materials can be found in Appendix E. Data Entry and Management All data were entered by the California Tribal Epidemiology Center Research Assistant. Paper forms were entered into a Microsoft 2007 Access database. All data were entered exactly how the participant filled out the survey. If a participant did not follow a skip pattern correctly, it was adjusted for in analysis. The Access database was exported into Excel, where 20% of the entered surveys were cross‐referenced with the hard copy by the project coordinator to determine accuracy of data entry. Corrections or discrepancies were noted and sent to the Research Assistant, who then made corrections and modifications to the Access database if necessary. The Access database was then imported into Statistical Package for the Social Sciences (SPSS) for data cleaning. SPSS version 17.0 and Statistical Analysis Software (SAS) version 9.2 were used to analyze data. Analysis to address Aim 1 Determine the prevalence of self‐reported asthma in AIANs in California. Study Population The study population includes all participants of the Tribal Asthma Survey Project (n=610) described in the Results section. Asthma was defined as answering “yes” to the question “Have you ever been told by a doctor or other health professional that you have asthma?” Analysis to Address Aim 2 Association between Allergens in Housing and Asthma Status Study Population The Tribal Asthma Survey Project (n=610) includes self‐identified AIAN participants, 18 years of age and older. Of the 610 participants, we excluded those who indicated that they resided in cars (n=1) or were homeless (n=18). Our final sample size was 591. Ascertainment of Allergens in Housing

• Type of home lived in (one‐family house, trailer (including mobile home), or other (including apartment, duplex, condo, or townhouse)

• Had a dog, cat, bird, chicken, pet mice or rats, gerbils, hamsters, rabbits, or other pet with fur or feathers living in home in the past six months (yes or no)

• Home near (within 200 feet) an open, dusty area (yes or no) • Uses an exhaust fan in the kitchen when cooking (yes or no) • Uses a mattress cover made especially for controlling dust mites (yes or no) • Has had water or dampness in their home from broken pipes, leaks, heavy rain, or floods (yes or no)

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• Has had mold in the home greater than the size of a dollar bill in the past 30 days, not including mold found on food (yes or no)

• Has seen or smelled mold or a musty odor inside their home in the past 30 days, not including mold found on food (yes or no)

• Has seen a cockroach inside their home in the past 30 days (yes or no) • Has seen mice or rats inside their home in the past 30 days, not including mice or rats kept as pets (yes

or no) Covariates

• Age (years) • Gender (male or female) • Body Mass Index (reported weight (pounds) was multiplied by 703 and then divided by total inches

squared) • Level of Education (≤High school graduate or >high school diploma) • Current employment status (employed or not employed) • Income (<$30,000, ≥$30,000) • Ever smoked 100 cigarettes (yes or no)

Statistical Analysis We assessed for the presence of effect measure modification (p<0.10) and determined that gender was a significant modifier of the housing issues‐asthma status relation; thus all multivariable model results were stratified by gender. The strength of associations between various housing issues and asthma were estimated by prevalence ratios (PRs) and 95% confidence intervals. Models were adjusted for age and smoking status.

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RESULTS

There were 610 surveys collected over the course of 7 months at 10 Indian events. Figure 1 shows the frequency of home zip codes for TASP survey participants; figure 2 shows the frequency of workplace zip codes. The Census 2000 American Indian/Alaska Native (AIAN) population (alone or in combination with one or more races) is displayed by county in both figures. In selecting events for survey dissemination, attempts were made to travel to counties with high AIAN populations. Additionally, survey locations that represented participants from Northern, Central, and Southern California geographic locations were prioritized.

Figure 1: Frequency of Home Zip Codes for TASP Participants

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Figure 2: Frequency of Workplace Zip Codes for TASP Participants

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CHARACTERISTICS OF THE TASP SAMPLE The characteristics of the participants are reported in Table 1. The majority of the sample was female (65%) and lived in California (94%). The mean age was 42.4 years (standard deviation (SD): 15.6), the mean Body Mass Index (BMI) was 32.0 (SD: 7.4), and 57% reported they had greater than a high school education. Over half of the sample (55%) reported they lived in a 1‐family house (Table 2A).

Table 1. Characteristics of Tribal Asthma Survey Project (TASP) population (n=610)

Variable n % Mean (SD)Sex

Male 196 32% Female 395 65% Missing 19 3%

Age (years) 18‐29 151 25%

42.4 (15.6)

30‐39 112 18% 40‐49 119 20% 50‐59 96 16% 60‐69 77 13% 70+ 22 4%

Missing 33 5%

Race/Ethnicity other than AIAN1 White 118 19%

Black or African American 20 3%Latino or Hispanic 136 22%

Asian 5 <1% Native Hawaiian 22 4%Pacific Islander 13 2%

Other 32 5%No Other Race ‐ AIAN Only 231 38%

Body Mass Index (BMI) 2 Normal Weight (18.0‐24.9) 80 13%

32.0 (7.3) Overweight (25.0‐29.9) 132 22%

Obese (30.0‐39.9) 210 34% Morbidly Obese (≥40.0) 67 11%

Missing 121 20% State of Residence

California 571 94% Other State 24 4%

Missing 15 3%

SD = Standard Deviation.

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Table 1 Continued. Characteristics of Tribal Asthma Survey Project (TASP) population (n=610)Variable n %Education Completed

High School Graduate or Less 246 40%Greater than High School 346 57%

Missing 18 3%Currently Employed

Yes 299 49%No 287 47%

Missing 24 4%Industry 3

Farming, Fishing and Forestry 1 0%Construction 12 4%

Management , Professional and Related Occupations 108 36%Production & Transportation 21 7%

Sales and Office 67 22%Service Occupations 63 21%

Missing 27 9%Occupation 3

Accommodation and Food Services 10 3%Administration 6 2%

Agriculture 5 2%Arts, Design, Entertainment, Sports & Media 16 5%

Construction 8 3%Education 17 6%

Finance and Insurance 5 2%Health Care and Social Assistance 111 37%

Information 2 1%Manufacturing 3 1%Other Service 4 1%

Professional, Scientific, and Technical Services 5 2%Public Administration 51 17%

Retail 12 4%Transportation and Warehousing 3 1%

Utilities 1 0%Wholesale Trade 3 1%

Missing 37 12%Household Income, Past Year

≤$20,000 204 33%$20,001 ‐ $40,000 159 26%

>$40,000 139 23%Missing 108 18%

1 Not mutually exclusive. 2 BMI was computed by converting reported heights to total inches. The reported weight (in pounds) was multiplied by 703 and then divided by height in total inches squared. One person was classified as being "underweight" and had not been diagnosed with asthma. 3 For those respondents who answered "yes" to "are you currently employed", n=299. Occupation and industry are based on the North American Industry Classification System (2002).

Missing: All participants who responded don’t know, I prefer not to answer, or who left the question blank.

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The TASP population demographics were compared to California statewide Census 2000 data (data not shown). The average per capita income for AIAN statewide by 1999 was $15,226, whereas for the TASP population, 33% of household incomes in the past year were $20,000 or less. More than a quarter of California AIANs (28.3%) currently in the labor force are in management, professional and profession‐related occupations, compared to 35% of the TASP population. The proportion (18%) of California AIANs in service occupations was comparable to the TASP population (21%). California AIANs are more likely to work in the production, transportation, and material moving industry (14.1%), to not have a high school diploma (26%), to have a bachelors degree (16%), and to indicate Hispanic or Latino ethnicity (46%), compared to the TASP population, 7%, 12%, 12%, and 22%, respectively. More than half (57.6%) of California AIANs are under the age of 35, whereas the mean age of the TASP population was 42.4 years (SD: 15.6). Only 22% of the TASP population indicated Hispanic or Latino ethnicity, compared to 46% of California AIANs.

Table 2A. Home Characteristics of TASP Population (n=610)

Variable n % What best describes the building you live in?

Mobile home/trailer 74 12% One‐family house 334 55%

Other 153 25% Missing 49 8%

Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. "Other" includes those who indicated they lived in a duplex, townhouse, or apartment complex.

Of participants who had a permanent non‐mobile residence (n=591), the average number of years at their current residence was 8.6 (SD: 10.5); there was an average of 3.7 (SD: 3.0) other people living in the home (Table 2B). Twenty‐eight percent lived on a reservation or Rancheria, and 38% were homeowners.

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Table 2B. Home Characteristics of TASP Population (n=591)

Variable n % Mean (SD) Year home built

1949 or earlier 47 8%

1950 to 1977 161 27%

1978 to present 273 46%

Missing 110 19%

How long have you lived in this home? (years)≤2 163 28%

2.7 (1.2)

2 to less than 5 102 17%

5 to less than 10 115 20%

10 to less than 25 Years 114 19%

≥25 Years 51 9%

Missing 46 8%

How many other people live in the home?None 20 3%

3.7 (3.0)

1 88 15%

2 101 17%

3 102 17%

4 78 13%

5 65 11%

6 45 8%

7 22 4%

8+ 30 5%

Missing 40 7%

Home on a reservation or RancheriaYes 164 28%

No 403 68%

Missing 24 4%

Own or rent home Own 226 38%

Rent 304 51%

Rent‐to‐Own 6 1%

Other 36 6%

Missing 19 3%

Home owned by a public housing authority1

Yes 58 16%

No 275 75%

Missing 32 9% 1 Asked of those who did not own their home, n=365 Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 17

Over a third (38%) of the sample reported that their home was less than 100 feet away from heavy traffic (Table 2C). Sixteen percent reported that trash was burned near their home; of those, 72% reported that trash was burned less than 100 feet away from home.

Table 2C. Home Characteristics of TASP Population: Potential Air Contaminants (n=591)

Variable n % Mean (SD)

Distance between location of heavy traffic and home

Right in front, behind, or beside the home 153 26% Less than 100 feet 72 12%

100‐300 feet 112 19% More than 300 feet 212 36%

Missing 42 7% Rail yard near the home?

Yes 46 8% No 509 86%

Missing 36 6% Home near an open, dusty area?

Yes 225 38% No 349 59%

Missing 17 3%

Home within 1/4 mile of a farm, ranch, or agricultural field? Yes 191 32% No 375 64%

Missing 25 4% Trash burned near home1

Yes 95 16% No 464 79%

Missing 32 5%

Distance between where trash is burned and home (feet) 1

≤100 31 51% 1563 (5330) >100 45 29%

Missing 19 20% 1 Asked of those who said they burned trash near their home (n=95) Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 18

Over half (56%) of the sample used an exhaust fan regularly when cooking in the kitchen; almost half used an exhaust fan in the bathroom (48%) (Table 2D). Fourteen percent used an air cleaner or air purifier in the home.

Table 2D. Home Characteristics of TASP Population: Ventilation (n=591)

Variable n %

Exhaust fan regularly used when cooking in kitchen

Yes 332 56% No 217 37%

Missing 42 7% Exhaust fan regularly used in bathroom

Yes 286 48% No 273 46%

Missing 32 5% Air cleaner/purifier used in home

Yes 81 14% No 463 78%

Missing 47 8%

What kind of air cleaner or purifier do you use1

Ozone generating/Ozonator 5 6% Ionizing/Ionic Cleaner/Electrostatic Cleaner 14 17%

HEPA Filter Cleaner 21 26% Missing 41 51%

How often do you change or wash the air filter(s)1

Once a week 2 3% Every 1‐4 months 38 47%

More than 4 months, up to 12 months 17 21% More than 12 months 6 7%

Never 3 4% Missing 15 19%

Dehumidifier regularly used to reduce moisture in home?

Yes 35 6% No 517 87%

Missing 39 7% 1 Asked of those who used an air cleaner or purifier in the home (n=81)

Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’.

Page | 19

Almost 70% of the sample used bleach or bleach products to clean their home (Table 2E), and half of the sample did not use pesticides either outdoors or in the home, respectively, to eliminate pests. For those who did use pesticides, chemicals, or sprays, the average number of days they were used was 7.9 (SD: 33.6) in the home and 7.2 (SD: 29.3) outdoors.

Table 2E. Home Characteristics of TASP Population: Sprays used in or around home (n=591)


Cleaning products used in home1 Bleach/Bleach Products 409 69%

Disinfectant sprays, wipes or solutions 451 76% Air Fresheners 272 46%

Green or non‐toxic products 161 27% Other 33 6%

Days pesticides, chemicals or sprays applied in home to kill bugs, mice, or other pests (past 12 months)

No Days 324 55%

7.9 (33.6)

1 ‐ 10 Days 68 12% 11 ‐ 20 Days 21 4% 21 ‐ 50 Days 21 4%

More than 50 Days 15 3% Missing 142 24%

Days pesticides, chemicals or sprays applied in yard or garden to kill bugs, mice, or other pests (past 12 months)

No Days 295 50%

7.2 (29.3)

1 ‐ 10 Days 55 9% 11 ‐ 20 Days 13 2% 21 ‐ 50 Days 20 3%

More than 50 Days 16 3% Does not have a yard/garden 54 9%

Missing 138 24% 1 Not mutually exclusive. Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

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Half of the sample had at least one pet living indoors in the past 6 months (Table 2F). In the past 30 days, 11% (n=66) had seen a cockroach in their home and 14% (n=85) had seen a mouse or rat in the home.

Table 2F. Home Characteristics of TASP Population: Animals in the Home (n=591)

Variable n %

Had any pets living in home in past 6 months?1

Dogs 218 37%

Cats 136 23%

Birds or Chickens 23 4%

Pet mice or rats 8 1%

Gerbils, hamsters or rabbits 14 2%

None 287 48%

Missing 11 2%

Seen cockroach in home (past 30 days)Yes 66 11%

No 492 83%

Missing 33 6%

Seen mice/rat in home (past 30 days, not including pets)

Yes 85 14%

No 479 81%

Missing 27 5%1 Not mutually exclusive.


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A fifth of the sample used a mattress cover to control for dust mites, and 13% used a pillow cover for the same purpose (Table 2G). Two‐thirds of the sample vacuumed their carpets or rugs within the last week.

Table 2G. Home Characteristics of TASP Population: Bed and Carpet (n=591)

Variable n %

Use mattress cover made for controlling dust mites? Yes 117 20% No 434 73%

Missing 40 7%

Use pillow cover made for controlling dust mites? Yes 79 13% No 480 81%

Missing 32 5%

Temperature used to wash sheets and pillowcases

Cold 133 23% Warm 176 30%

Hot 223 38% Varies 45 8%

Missing 14 3% When was carpet/rug last vacuumed?

1 to 6 Days Ago 368 62% 7 days to 2 weeks ago 72 12%

More than 2 weeks to 1 month ago 23 4% More than 1 month to 2 months ago 9 2%

More than 2 months ago 24 4% Does not have carpet/rugs 61 10%

Missing 34 6% Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’.

Page | 22

Over 40% of the sample reported water damage in their home, and over a quarter had seen mold in their home in the past 30 days (Table 2H). A quarter of the sample used a wood burning stove or fireplace to heat their home; the average number of days a wood stove, fireplace, or kerosene heater was used in the home in the past year was 39.3 (SD: 74.2).

Table 2H. Home Characteristics of TASP Population: Heating & Conditions (n=591)


When it's cold, how do you heat your home?1

Gas or electric central heating 429 72% Space Heaters 65 11%

Wood burning stove or fireplace 154 26% No source of heat 15 3%

Other 21 4% How many days used a wood stove, fireplace, or kerosene heater in the home (past 12 months)?

None 243 41%

39.3 (74.2)

1 ‐10 25 4% 11 ‐ 50 28 5%

51 ‐ 100 31 5% More than 100 62 11%

No wood stove, fireplace or kerosene heater 130 22% Missing 72 12%

Gas used for cooking Yes 424 72% No 150 25%

Missing 17 3% Ever been water or dampness in home from broken pipes, leaks, heavy rains, or floods?

Yes 246 41% No 300 51%

Missing 45 8% Mold in home greater than the size of a dollar bill in the past 30 days?

Yes 152 26% No 387 65%

Missing 52 9% Anyone seen or smelled mold or a musty odor in the home in the past 30 days?

Yes 158 27% No 394 66%

Missing 39 7% 1 Not mutually exclusive. Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 23

LEVEL OF CONCERN FOR POTENTIAL ALLERGENS IN THE HOME Respondents were asked to rank their level of concern on eight potential allergens in the home (Table 3A). Almost half of the sample (48%) reported that they were “very concerned” about pests (rodents or cockroaches) and mold or moisture in the home (47%).

Table 3A. Level of Concern for Potential Allergens in the Home of the TASP Population (n=610)

n % Mold or Moisture

Not at all concerned 107 18% Not too concerned 71 12%

Somewhat concerned 123 20% Very Concerned 286 47%

Missing 23 4% Outdoor Air Pollution



Missing 26 4% Old Carpeting



Missing 24 4% Fumes from New Furniture, Flooring or Carpeting



Missing 27 4% Pests (such as rodents or cockroaches)



Missing 24 4% Cleaning Chemicals



Missing 25 4%

Page | 24

Table 3A Continued. Level of Concern for Potential Allergens in the Home of the TASP Population (n=610) Variable n % Commercial Tobacco smoked in the home

Not at all concerned 191 31%Not too concerned 79 13%

Somewhat concerned 57 9%Very Concerned 250 41%

Missing 33 5%Second‐hand smoke drifting in to the home

Not at all concerned 175 29%Not too concerned 86 14%

Somewhat concerned 62 10%Very Concerned 257 42%

Missing 30 5%1 Not mutually exclusive. Missing: All participants who responded don’t know, I prefer not to answer, or who left the question blank.

Page | 25

Participants were also asked if they thought the issues mentioned for concern would be issues of concern for other people in their neighborhood (Table 3B). Of those who responded yes (n=243), Mold or Moisture and Pests were the two highest responses 74% and 68% agreed that these issues were of concern for others in their neighborhood, respectively.

Table 3B. Do you think any of the following issues are health concerns for others in your neighborhood (n=243)?

Variable n % Mold or Moisture

179 74% Outdoor Air Pollution

162 67% Old Carpeting

135 56% Fumes from New Furniture, Flooring or Carpeting

92 38% Pests (such as rodents or cockroaches)

165 68% Cleaning Chemicals

124 51% Commercial Tobacco smoked in the home

119 24% Second‐hand smoke drifting in to the home

124 51%

Missing: All participants who responded don’t know, I prefer not to answer, or who left the question blank.

Asked of those who did not answered "yes" to the question "of the issues we just mentioned, do you think any of these are health concerns for others in your neighborhood?", n=243.

Note: Percentages and frequencies are not mutually exclusive.

ASTHMA STATUS Twenty‐one percent (n=131) of the sample had been diagnosed by a doctor or other health professional with asthma (Table 4). Of those diagnosed with asthma, the sample was 76% female with a mean age of 44.6 years (SD: 15.5). The crude prevalence of asthma was 14.3% for males and 25.3% for females.

Page | 26

Table 4. Characteristics of Tribal Asthma Survey Project (TASP) population by Asthma Status (n=582)

Ever Diagnosed with Asthma Yes (n=131) No (n=451)

Variable n % Mean (SD) n % Mean (SD)Sex

Male 28 22% 159 36% Age (years)

18‐29 25 20%

44.6 (15.5)

121 28%

41.5 (15.5)

30‐39 27 22% 84 20% 40‐49 21 17% 92 21% 50‐59 22 18% 70 16% 60‐69 26 21% 47 11% 70+ 4 3% 16 4%

Race/Ethnicity other than American Indian/Alaska Native (AIAN)1

White 31 24% 83 18% Black or African American 6 5% 14 3%

Latino or Hispanic 26 20% 105 23% Asian 2 2% 3 1%

Native Hawaiian 3 2% 16 4% Pacific Islander 4 3% 9 2%

Other 8 6% 30 7% No Other Race ‐ AIAN Only 47 36% 175 39%

Body Mass Index (BMI)2 Normal Weight (<25) 20 20%

32.2 (8.1)

52 15%

32.0 (7.2) Overweight (25.0‐29.9) 21 21% 94 28%

Obese (30.0‐39.9) 42 42% 146 43% Morbidly Obese (≥40.0) 17 17% 47 14%

State of Residence California 122 95% 426 95%

Education High School Graduate or less 43 34% 190 43%

Currently Employed Yes 70 54% 223 51%

Household Income ≤$20,000 40 35% 152 42%

$20,001 ‐ $40,000 40 35% 114 31% >$40,000 36 31% 99 27%

1 Not mutually exclusive. 2 BMI was computed by converting all respondent reported heights (in feet and inches) to total inches (inches + (feet*12)). The reported weight (in pounds) was multiplied by 703 and then divided by the total inches squared. One person was classified as being "underweight" and had not been diagnosed with asthma. SD = Standard Deviation

Page | 27

ASTHMA CO‐MORBIDITIES Of those who had been diagnosed with asthma (n=131, see Table 4), 76% still had asthma (Table 5). The mean age of diagnosis was 27.1 years (SD: 17.9). Almost half (49%) reported that their asthma had been made worse by workplace conditions. In the past 30 days, the average number of days that respondents reported they had symptoms of asthma (which was defined as coughing, wheezing, shortness of breath, chest tightness, or phlegm production when you do not have a cold or respiratory infection) was 9.1 (SD: 10.2).

Table 5. Asthma morbidity in TASP population ever diagnosed with asthma (n=131) Variable n % Mean (SD) Age Diagnosed with Asthma (years)

Infant ‐ 12 32 24%

27.1 (17.9)

13‐18 19 15% 19‐30 23 18% 31‐50 31 24% 51+ 14 11%

Missing 12 9% Still have asthma

Yes 99 76% No 21 16%

Missing 11 8% Asthma made worse by chemicals, smoke, fumes, or dust in the workplace

Yes 64 49% No 42 32%

Missing 25 19% How many times seen doctor for routine asthma checkup in the past 12 months

None 27 21%

6.2 (14.5)

1 time 16 12% 2 times 13 10%

3 ‐ 10 times 31 24% More than 10 times 11 8%

Missing 33 25% How long since last asthma medication

Never 4 3% Less than 1 day ago 27 21%

1‐6 days ago 27 21% 1 week to less than 3 months ago 14 11% 3 months to less than 1 year ago 20 15% 1 year to less than 3 years ago 13 10% 3 years to less than 5 years ago 6 5%

More than 5 years 16 12% Missing 4 3%

Page | 28

Table 5 Continued. Asthma morbidity in TASP population ever diagnosed with asthma (n=131)

Variable n % Mean (SD)How long since last symptoms of asthma?

Never 7 5% Less than 1 day ago 21 16%

1‐6 days ago 38 29% 1 week to less than 3 months ago 19 15% 3 months to less than 1 year ago 24 18% 1 year to less than 3 years ago 5 4% 3 years to less than 5 years ago 2 2%

More than 5 years 10 8% Missing 5 4%

How many days with symptoms of asthma (past 30 days)1

None 4 5%

9.1 (10.2)

1 Day 8 10% 2‐5 Days 25 31%

6‐10 Days 6 7% More than 10 Days 22 27%

Missing 17 21% How many days with symptoms of asthma made it difficult to sleep (past 30 days)1

None 23 37%

5.4 (8.5)

1 Day 6 10% 2‐5 Days 10 16%


Missing 7 11%

How many asthma attacks or episodes (past 3 months)2

None 22 28%

5.6 (14.9)

1 Day 13 17% 2‐5 Days 21 27%


Missing 10 13%

Page | 29

Table 5 Continued. Asthma morbidity in TASP population ever diagnosed with asthma (n=131)


How many times visited emergency room because of asthma (past 12 months) 3

None 74 67%

1.4 (5.6)

1 Day 5 5% 2‐5 Days 15 15%

6‐10 Days 1 <1% More than 10 Days 2 2%

Missing 5 9% How many times overnight stay in hospital because of asthma (past 12 months) 3

None 92 90%

0.05 (0.27) 1 Day 3 3% 2 Days 1 <1% Missing 6 6%

How many days work/school missed because of asthma (past 12 months) 3

None 77 71%

1.6 (5.0) 1‐5 Days 10 10% 6‐30 Days 7 7% Missing 8 13%

Did asthma limit usual activities (past 12 months) 3

Not at all 22 22% A little 50 49%

A Moderate Amount 13 13% A Lot 10 10%

Missing 7 7%

What do you usually do when you have symptoms of asthma? 4

Take prescribed medicine (i.e., inhaler) 98 75% Take non‐prescription medicine 16 12% Go to a doctor, clinic, or hospital 31 24%

Go to a native healer/medicine man 3 2% Use traditional medicines 9 7%

Wait until it passes 29 22% Missing 5 4%

1 Asked of respondents who reported they had symptoms of asthma in the past 30 days (n=62). 2 Asked of respondents who reported they had symptoms of asthma in the past 3 months (n=78). 3 Asked of respondents who reported they had symptoms of asthma in the past 12months (n=102). 4 Not mutually exclusive. Missing: All participants who responded don’t know, I prefer not to answer, or who left the question blank. SD = Standard Deviation

Page | 30

ASTHMA STATUS AND HOUSING CONDITIONS

Table 6A. Home Characteristics in TASP Population by Asthma Status (n=582)

Variable Ever Diagnosed with Asthma

Yes (n=131) No (n=451)n % n %

What best describes the building you live in? Mobile home/trailer 13 10% 60 15%

One‐family house 85 66% 234 57%Other 27 24% 108 29%


"Other" includes those who indicated they lived in a duplex, townhouse, or apartment complex.

Page | 31

Table 6B. Home Characteristics in TASP Population by Asthma Status (n=568)

Variable Ever Diagnosed with Asthma Yes (n=131) No (n=437)

n % Mean (SD) n % Mean (SD)

Year home built 1949 or earlier 12 11% 31 9% 1950 to 1977 36 32% 120 34%

1978 to present 65 58% 200 57%

How long have you lived in this home? (years)

≤ 1 19 16%

9.3 (10.8)

73 18%

8.4 (10.6)

1 to less than 5 32 26% 132 33% 5 to less than 10 30 25% 80 20%

10 to less than 25 Years 29 24% 83 20% ≥ 25 Years 12 10% 38 9%

How many other people live in the home?

None 3 2%

3.4 (2.4)

16 4%

3.7 (3.2)

1 21 17% 64 16% 2 23 18% 74 18% 3 25 20% 75 18% 4 20 16% 57 14% 5 20 16% 43 11% 6 6 5% 37 9% 7 4 3% 17 4% 8+ 3 2% 26 6%

Home on a reservation or Rancheria Yes 34 27% 126 30% No 91 73% 297 70%

Own or rent home Own 55 43% 165 39% Rent 65 50% 227 54%

Rent‐to‐Own 0 0% 6 1% Other 9 7% 25 6%

Home owned by a public housing authority1

Yes 13 18% 37 16% No 58 82% 198 84%

1 Asked of those who did not own their home, n=332Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 32

Table 6C. Home Characteristics in the TASP Population: Potential Air Contaminants by Asthma Status (n=568)


Yes (n=131) No (n=437)n % Mean (SD) n % Mean (SD)


Right in front, behind, or beside the home 32 26% 113 28% 410 Less than 100 feet 21 17% 51 12%

100‐300 feet 27 22% 80 20% More than 300 feet 43 35% 166 40%

Rail yard near the home? Yes 12 10% 33 8% No 109 90% 381 92%

Home near an open, dusty area? Yes 56 46% 161 37% No 66 54% 271 63%

Home within 1/4 mile of a farm, ranch, or agricultural field?

Yes 45 36% 140 33% No 81 64% 283 66%

Trash burned near home Yes 19 15% 73 17% No 106 85% 349 83%

Distance between where trash is burned and home (feet)1

≤100 6 46% 3309 (10213)

24 39% 1221 (3688) >100 7 54% 38 61%

1 Asked of those who said they burned trash near their home (n=92) Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 33

Table 6D. Home Characteristics in the TASP Population: Ventilation by Asthma Status (n=568)

Variable Ever Diagnosed with Asthma Yes (n=131) No (n=437)n % n %

Exhaust fan regularly used when cooking in kitchen

Yes 85 69% 235 58%

No 39 31% 172 42%

Exhaust fan regularly used in bathroom Yes 68 53% 210 51%

No 60 47% 202 49%

Air cleaner/purifier used in home Yes 20 16% 54 13%

No 104 84% 351 87%

What kind of air cleaner or purifier do you use1 Ozone generating/Ozonator 1 13% 3 10%

Ionizing/Ionic Cleaner/Electrostatic Cleaner 1 13% 12 41%

HEPA Filter Cleaner 6 75% 14 48%

How often do you change or wash the air filter(s)1

Once a week 0 0% 2 5%

Every 1‐4 months 10 53% 26 62%

More than 4 months, up to 12 months 7 37% 8 19%

More than 12 months 1 5% 5 12%

Never 1 5% 1 2%


Yes 10 8% 19 5%

No 114 92% 392 95%1 Asked of those who used an air cleaner or purifier in the home (n=74)


Page | 34

Table 6E. Home Characteristics in the TASP Population : Sprays used in or around home by Asthma Status (n=568)



Cleaning products used in home1 Bleach/Bleach Products 92 70% 303 69%

Disinfectant sprays, wipes or solutions 99 76% 340 78% Air Fresheners 62 47% 205 47%

Green or non‐toxic products 38 29% 118 27% Other 8 6% 24 5%


No Days 68 64%

15.7 (51.4)

245 75%

6.5 (30.5) 1 ‐ 10 Days 16 15% 48 15%

11 ‐ 20 Days 10 9% 11 3% 21 ‐ 50 Days 7 7% 14 4%

More than 50 Days 6 6% 9 3%


No Days 59 45%

12.8 (43.3)

226 52%

4.7 (17.6) 1 ‐ 10 Days 13 10% 39 9%

11 ‐ 20 Days 7 5% 6 1% 21 ‐ 50 Days 7 5% 12 3%

More than 50 Days 7 5% 9 2% Does not have a garden or yard 15 11% 39 9%

1 Not mutually exclusive. Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

Page | 35

Table 6F. Home Characteristics in the TASP Population: Animals in the Home by Asthma Status (n=568)

Variable Ever Diagnosed with Asthma Yes (n=131) No (n=437)n % n %

Had any pets living in home in past 6 months?1 Dogs 56 43% 155 35%

Cats 37 28% 92 21%

Birds or Chickens 7 5% 15 3%

Pet mice or rats 2 2% 5 1%

Gerbils, hamsters or rabbits 6 5% 6 1%

None 48 37% 232 53%

Seen cockroach in home (past 30 days) Yes 14 11% 46 11%

No 111 89% 369 89%


Yes 18 14% 64 15%

No 108 86% 354 85%1 Not mutually exclusive.


Page | 36

Table 6G. Home Characteristics in the TASP Population: Bed and Carpet by Asthma Status (n=568)

Variable Ever Diagnosed with AsthmaYes (n=131) No (n=437)n % n %

Use mattress cover made for controlling dust mites?

Yes 34 28% 77 19%

No 89 72% 331 81%

Use pillow cover made for controlling dust mites?

Yes 20 16% 51 12%

No 106 84% 361 88%

Temperature used to wash sheets and pillowcases

Cold 26 20% 103 24%

Warm 37 30% 133 31%

Hot 53 41% 162 38%

Varies 13 10% 31 7%

When was carpet/rug last vacuumed?

1 to 6 Days Ago 95 74% 267 65%

7 days to 2 weeks ago 12 9% 54 13%

More than 2 weeks to 1 month ago 7 5% 16 4%

More than 1 month to 2 months ago 1 1% 5 1%

More than 2 months ago 2 2% 22 5%

Does not have carpet/rugs 12 9% 45 11%


Page | 37

Table 6H. Home Characteristics in the TASP Population: Heating & Conditions by Asthma Status (n=568)




Gas or electric central heating 96 73% 316 72% Space Heaters 17 13% 46 11%

Wood burning stove or fireplace 31 24% 120 27% No source of heat 6 5% 8 2%

Other 6 5% 14 3%

How many days used a wood stove, fireplace, or kerosene heater in the home (past 12 months)?

None 56 48%

25.0 (55.2)

181 47%

44.4 (79.1)

1 ‐10 Days 7 6% 16 4% 11 ‐ 50 Days 9 8% 19 5%

51 ‐ 100 Days 5 4% 25 6% More than 100 Days 9 8% 54 14%

No wood stove, fireplace or kerosene heater 31 26% 92 24% Gas used for cooking

Yes 96 76% 308 72% No 31 24% 118 28%

Ever been water or dampness in home from broken pipes, leaks, heavy rains, or floods?

Yes 65 53% 176 43% No 57 47% 232 57%

Mold in home greater than the size of a dollar bill in the past 30 days?

Yes 48 39% 97 24% No 74 61% 303 76%

Anyone seen or smelled mold or a musty odor in the home in the past 30 days?

Yes 49 40% 102 25% No 74 61% 309 75%


Page | 38

LEVEL OF CONCERN FOR HOME AIR CONTAMINANTS BY ASTHMA STATUS Table 7. Level of Concern for Home Air Contaminants in the TASP Population by Asthma Status (n=582)

Variable Ever Diagnosed with AsthmaYes (n=131) No (n=437)n % n %

Mold or Moisture Not at all concerned 18 14% 84 19%Not too concerned 14 11% 55 13%

Somewhat concerned 32 25% 87 20%Very concerned 65 50% 209 48%

Outdoor Air Pollution Not at all concerned 17 13% 60 14%Not too concerned 12 9% 75 17%


Old Carpeting Not at all concerned 18 14% 107 25%Not too concerned 20 15% 76 18%


Fumes from New Furniture, Flooring or Carpeting Not at all concerned 33 26% 116 27%Not too concerned 34 26% 111 26%


Pests (such as rodents or cockroaches) Not at all concerned 33 25% 102 24%Not too concerned 17 13% 54 12%


Cleaning Chemicals Not at all concerned 23 18% 87 20%Not too concerned 19 15% 96 22%


Commercial Tobacco smoked in the home Not at all concerned 39 31% 144 34%Not too concerned 16 13% 61 14%


Second‐hand smoke drifting in to the home Not at all concerned 32 25% 136 32%Not too concerned 16 13% 68 16%


Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, or did not answer Yes or No to the question "have you ever been told by a doctor or other health professional that you have asthma?".

Page | 39

PEDIATRIC ASTHMA

Table 8. Children under the age of 18 living at home (n=652).

Variable n % Mean (SD) Sex

Male 283 43%Female 301 46%Missing 68 10%

Age 1 year old or younger 34 5%

8.9 Years (5.1 Years)

2 ‐ 5 years old 76 12%6‐10 years old 95 15%

11‐15 years old 102 16%16 ‐ 18 years old 48 7%

Missing 297 46%

Race 1 American Indian or Alaska Native 89 14%

White 65 10%Black 32 5%Asian 3 0%

Native Hawaiian/Pacific Islander 14 2%Hispanic 127 19%

Some other race 8 1%Has child been diagnosed with asthma?

Yes 138 21%No 469 72%

Missing 45 7%

Does child still have asthma? 2 Yes 109 79%No 22 16%

Missing 7 5%

Had symptoms, taken medication, or seen a doctor for asthma in the past 12 months? 2

Yes 98 71%No 37 27%

Missing 3 2%1 Not mutually exclusive. 2 Includes only those who answered "yes" to "child has been diagnosed by a doctor or other health professional with asthma", n=138. SD = Standard Deviation

Page | 40

PUBLIC HOUSING

Table 9A. Home Characteristics in the TASP Population by Public Housing Status (n=389)

Variable

Home owned by Public Housing Authority

Yes (n=63) No (n=326)n % n %

What best describes the building you live in? Mobile home/trailer 5 9% 29 10%

One‐family house 35 62% 160 53%Duplex or Townhouse 2 4% 42 14%

Apartment complex or Condo 14 25% 69 23%Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’.

Page | 41

Table 9B. Home Characteristics of the TASP Population by Public Housing Status (n=389)

Variable Home owned by Public Housing Authority

Yes (n=63) No (n=326) n % Mean (SD) n % Mean (SD)


1978 to present 34 69% 130 51% How long have you lived in this home? (years)

≤ 1 11 21%

7.2 (8.6)

73 24%

6.5 (9.8) 1 to less than 5 15 29% 117 38%

5 to less than 10 12 23% 48 16% 10 to less than 25 Years 11 21% 48 16%

≥ 25 Years 3 6% 19 6% How many other people live in the home?

None 2 4%

4.4 (4.5)

11 4%

3.7 (3.0)

1 4 7% 47 15% 2 17 31% 50 16% 3 5 9% 63 20% 4 6 11% 49 16% 5 7 13% 46 15% 6 7 13% 20 6% 7 3 5% 10 3% 8+ 4 7% 14 5%

Home on a reservation or Rancheria Yes 35 59% 51 16% No 24 41% 263 84%

1 Asked of those who did not own their home, n=306 Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

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Table 9C. Home Characteristics of the TASP Population: Potential Air Contaminants by Public Housing Status (n=389)

Variable Home owned by Public Housing Authority Yes (n=63) No (n=326)



Right in front, behind, or beside the home 20 38% 90 29%

Less than 100 feet 5 9% 55 18% 100‐300 feet 16 30% 58 19%

More than 300 feet 12 23% 100 32% Rail yard near the home?

Yes 5 8% 28 9% No 55 92% 285 91%



Yes 26 45% 91 29% No 32 55% 223 71%



≤100 7 64% 557 (1585)

13 42% 1624 (6685) >100 4 36% 18 58%

1 Asked of those who said they burned trash near their home (n=55) Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’. SD = Standard Deviation

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Table 9D. Home Characteristics: Ventilation by Public Housing Status (n=389)

Variable


Yes (n=63) No (n=326)n % n %

Exhaust fan regularly used when cooking in kitchen Yes 42 74% 171 56%

No 15 26% 132 44%

Exhaust fan regularly used in bathroom

Yes 34 60% 146 48%

No 23 40% 160 52%

Air cleaner/purifier used in home

Yes 5 10% 46 15%

No 46 90% 254 85%


Yes 4 17% 19 6%

No 19 83% 285 94%


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Table 9E. Home Characteristics of the TASP Population: Sprays used in or around home by Public Housing Status (n=389)



Cleaning products used in home1 Bleach/Bleach Products 40 63% 222 68%

Disinfectant sprays, wipes or solutions 29 45% 249 76% Air Fresheners 27 42% 151 46%

Green or non‐toxic products 7 11% 95 29% Other 6 9% 19 6%


No Days 31 78%

5.3 (17.1)

175 72%

10.1 (42.6) 1 ‐ 10 Days 5 13% 41 17%

11 ‐ 20 Days 1 3% 8 3% 21 ‐ 50 Days 1 3% 10 4%

More than 50 Days 2 5% 10 4%


No Days 25 78%

2.7 (14.5)

158 65%

8.2 (37.2) 1 ‐ 10 Days 2 6% 30 12%

11 ‐ 20 Days 1 3% 4 2% 21 ‐ 50 Days 0 0% 7 3%

More than 50 Days 1 3% 9 4% Does not have a garden or yard 3 9% 35 14%


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Table 9F. Home Characteristics of the TASP Population: Animals in the Home by Public Housing Status (n=389)

Variable


Yes (n=63) No (n=326)n % n %

Had any pets living in home in past 6 months?1

Dogs 17 27% 113 35%

Cats 11 17% 64 20%

Birds or Chickens 3 5% 12 4%

Pet mice or rats 0 0% 6 2%

Gerbils, hamsters or rabbits 0 0% 8 2%

None 40 63% 168 52%

Seen cockroach in home (past 30 days)

Yes 8 14% 42 14%

No 50 86% 265 86%


Yes 8 13% 44 14%

No 52 87% 268 86%1 Not mutually exclusive.


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Table 9G. Home Characteristics of the TASP Population: Bed and Carpet by Public Housing Status (n=389)

Variable


Yes (n=63) No (n=326)n % n %

Use mattress cover made for controlling dust mites?

Yes 7 12% 71 23%

No 50 88% 238 77%

Use pillow cover made for controlling dust mites? Yes 5 9% 45 15%

No 53 91% 265 85%

Temperature used to wash sheets and pillowcases Cold 11 19% 76 24%

Warm 16 27% 95 30%

Hot 24 41% 126 39%

Varies 8 14% 24 7%

When was carpet/rug last vacuumed? 1 to 6 Days Ago 36 67% 209 67%

7 days to 2 weeks ago 3 6% 41 13%

More than 2 weeks to 1 month ago 1 2% 13 4%

More than 1 month to 2 months ago 1 2% 4 1%

More than 2 months ago 3 6% 15 5%

Does not have carpet/rugs 10 19% 31 10%


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Table 9H. Home Characteristics of the TASP Population: Heating & Conditions by Public Housing Status (n=389)




Gas or electric central heating 48 75% 248 76% Space Heaters 3 5% 37 11%

Wood burning stove or fireplace 24 38% 56 17% No source of heat 0 0% 9 3%

Other 0 0% 11 3%

How many days used a wood stove, fireplace, or kerosene heater in the home (past 12 months)?

None 22 43%

49.8 (76.9)

157 54%

29.5 (72.1)

1 ‐10 Days 3 6% 9 3% 11 ‐ 50 Days 5 10% 11 4%

More than 50 Days 11 22% 33 11%

No wood stove, fireplace or kerosene heater 10 20% 79 27%

Gas used for cooking

Yes 51 85% 217 68% No 9 15% 101 32%


Yes 28 49% 133 45% No 29 51% 164 55%


Yes 16 29% 92 30% No 39 71% 210 70%


Yes 13 23% 102 33% No 44 77% 203 67%


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RENTERS

Table 10A. Home Characteristics of the TASP Population by Home Ownership Status (n=530)

Variable Do you own or rent your home?

Own (n=226) Rent (n=304) n % Mean (SD) n % Mean (SD)


1978 to present 126 58% 121 55% How many other people live in the home?

None 9 4%

3.3 (2.4)

10 3%

3.6 (2.6)

1 47 22% 38 13% 2 41 19% 58 20% 3 37 17% 55 19% 4 28 13% 40 14% 5 17 8% 41 14% 6 18 8% 20 7% 7 10 5% 8 3% 8+ 11 5% 16 6%


Yes 106 49% 114 41% No 111 51% 163 59%


Yes 60 29% 78 28% No 146 61% 202 62%


Yes 58 27% 88 31% No 158 73% 197 69%

Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’, and who did not answer the question “do you rent or own your home”. SD = Standard Deviation

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Table 10B. Home Characteristics of the TASP Population by Home Ownership Status (n=530)

Variable Do you own or rent your home?

Own (n=226) Rent (n=304)n % Mean (SD) n % Mean (SD)


Right in front, behind, or beside the home 49 23% 83 30%

Less than 100 feet 17 8% 49 18% 100‐300 feet 38 18% 60 22%

More than 300 feet 111 52% 86 31% Rail yard near the home?

Yes 11 5% 33 11% No 197 95% 258 89%



Yes 90 41% 81 28% No 130 59% 206 72%



≤100 17 35% 1878 (6256)

8 53% 426 (1358) >100 31 65% 7 47%

1 Asked of those who said they burned trash near their home (n=78) Missing: All participants who responded don’t know, I prefer not to answer, who left the question blank, marked ‘homeless’ or ‘lived in vehicle’, and who did not answer the question “do you rent or own your home”. SD = Standard Deviation

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MULTIVARIABLE ANALYSIS After adjusting for age and smoking status, the prevalence of asthma in women was 1.67 (CI: 1.16, 2.40) times as high in those with pets with fur or feathers in the home in the past 6 months compared to those without pets with fur or feathers (Table 11B). The prevalences of asthma in women were also higher in those who have seen mold greater than the size of a dollar bill (PR: 1.84, CI: 1.28, 2.65) and have smelled a moldy or musty odor (PR: 1.54, CI: 1.07, 2.21), in their home in the past 30 days compared to those who have not seen or smelled mold in their home. Among men, there were no associations between potential allergens in housing and asthma status (Table 11A). No statistically significant associations between socioeconomic status and asthma were observed in both men and women.

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Table 11A. Adjusted prevalence ratios and 95% confidence intervals of asthma status by housing issues and socioeconomic status in males. The Tribal Asthma Survey Project (TASP) (n=186). Housing issue PR 95% CI CLRType of home Other Trailer One‐family

0.59 0.52 1

(0.23, 1.47) (0.13, 2.02)

.

6.39 15.5 .

Pets living inside your home, past 6 months Yes No

1.75 1

(0.84, 3.63)

.

4.32 .

Home near dusty field Yes No

1.51 1

(0.72, 3.15)

.

4.38 .

Use exhaust fan when cooking Yes No

0.60 1

(0.27, 1.29)

.

4.78 .

Use a mattress cover No Yes

0.49 1

(0.23, 1.08)

.

4.70 .

Ever dampness in home Yes No

1.69 1

(0.78, 3.68)

.

4.72 .

Mold greater than dollar bill, past 30 days Yes No

1.45 1

(0.70, 3.03)

.

4.33 .

Seen or smelled mold, past 30 days Yes No

2.00 1

(0.93, 4.26)

.

4.58 .

Seen mice or rats, past 30 days Yes No

0.76 1

(0.28, 2.08)

.

7.43 .

Seen cockroach, past 30 days Yes No

0.79 1

(0.26, 2.41)

.

9.27 .

Socioeconomic Status Household income, past year <$30,000 $30,000 and greater

0.91 1

(0.42, 1.97)

.

4.69 .

Highest education completed High school or less Greater than high school

0.54 1

(0.25, 1.17)

.

4.68 .

Currently employed Yes No

1.30 1

(0.62, 2.71)

.

4.37 .

*Asthma status is defined as self‐reported ever diagnosis by a physician. The referent group is no‐asthma status. †PR = prevalence ratio ‡CI= confidence interval §CLR = confidence limit ratio # “Other” type of home includes those who indicated they lived in a duplex, condo, townhouse, or apartment complex. ** Models adjusted for age and smoking status.

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Table 11B. Adjusted prevalence ratios and 95% confidence intervals of asthma status by housing issues and socioeconomic status in females. The Tribal Asthma Survey Project (TASP) (n=186). Housing issue PR 95% CI CLRType of home Other Trailer One‐family

0.94 0.66 1

(0.62, 1.42) (0.37, 1.17)

.

2.29 3.16 .

Pets living inside your home, past 6 months Yes No

1.67 1

(1.16, 2.40)

.

2.07 .

Home near dusty field Yes No

1.22 1

(0.85, 1.75)

.

2.06 .

Use exhaust fan when cooking Yes No

0.80 1

(0.55, 1.16)

.

2.11 .

Use a mattress cover No Yes

0.69 1

(0.46, 1.04)

.

2.26 .

Ever dampness in home Yes No

1.19 1

(0.83, 1.69)

.

2.04 .

Mold greater than dollar bill, past 30 days Yes No

1.84 1

(1.28, 2.65)

.

2.07 .

Seen or smelled mold, past 30 days Yes No

1.54 1

(1.07, 2.21)

.

2.07 .

Seen mice or rats, past 30 days Yes No

1.08 1

(0.65, 1.80)

.

2.77 .

Seen cockroach, past 30 days Yes No

1.07 1

(0.59, 1.94)

.

3.29 .

Socioeconomic Status Household income, past year <$30,000 $30,000 and greater

0.96 1

(0.67, 1.39)

.

2.07 .

Highest education completed High school or less Greater than high school

0.87 1

(0.60, 1.26)

.

2.10 .

Currently employed Yes No

0.96 1

(0.67, 1.36)

.

2.03 .

*Asthma status is defined as self‐reported ever diagnosis by a physician. The referent group is no‐asthma status. †PR = prevalence ratio ‡CI= confidence interval §CLR = confidence limit ratio # “Other” type of home includes those who indicated they lived in a duplex, condo, townhouse, or apartment complex. ** Models adjusted for age and smoking status.

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DISCUSSION

Using the methods listed above, 610 surveys were collected at multiple AIAN cultural events in California. Due to the limitations in the methods used to administer the surveys, this was an acceptable number of surveys to collect. Further collection of additional surveys at additional cultural events could have led to a risk of duplicate surveys, since there are potentially several people traveling to multiple events (e.g. vendors travel to Pow‐Wows and Big Times at locations throughout California and there is overlap with Board, Tribal, and Annual consultation meetings with elected tribal officials). Given more time and funding to pursue in‐person interviews would have allowed us to collect additional surveys while minimizing duplicate surveys. CTEC collected 610 surveys, exceeding the original goal of 450. Limitations The study population was a sample of convenience. Non‐California residents were included (n=24; 4%). However, results did not change when non‐California residents were removed from analysis. Non‐California residents were retained in the sample because there are a small number of reservations in California that extend into Arizona. Many California cultural events happen between the months of May and October. Several events were missed due to the time frame in which funding was available (October – June). In addition to administering the survey, creating the survey instrument and entering, cleaning, and analyzing the data exhausted a majority of the time between October and June. Participants were self‐identified AIAN. Staff administering the survey at cultural events did not check tribal enrollment cards or Certificates of Degree of Indian Blood (CDIB) papers from the Bureau of Indian Affairs (BIA). Since approximately 50 tribes in California are not federally recognized and are seeking restoration or recognition, it was likely individuals from these tribes would not have tribal enrollment cards. Additionally, it is not common for AIAN individuals to carry CDIB papers. In California, descendents of Indians on the 1852 Census Rolls are eligible for health care benefits, regardless of their tribal federal recognition status. Strengths This study gathered asthma and housing condition data, which can empower tribes to determine program priorities, direct program planning, develop new policies and culturally appropriate intervention strategies. Word‐of‐mouth was a key component in recruiting survey participants. Upon completion of the survey, several people informed their respective networks of the survey and incentive opportunity. A majority of participants were recruited in this manner. The $15 gift cards proved to be a strong incentive for event attendees to participate in the TASP study – due to both word‐of‐mouth and visible signage. Upon completion of the survey, several participants had anecdotal stories to tell regarding their experience with asthma, whether they, a friend or family member had suffered from the condition. Several participants related their experiences with attempting to obtain medical care for their asthma with little success. Many commented that the survey “really made them think” about asthma and potential housing allergens as precipitators of asthma morbidity. The distribution of free, culturally‐specific health education materials on asthma, asthma morbidity, and home environment proved to be a great strength of the project. Recommendations The prevalence of asthma in California AIANs is greater than the national prevalence in both AIANs and Whites. From 2004‐2008, the national prevalence of asthma was 14.2% for AIAN and 11.6% for non‐Hispanic

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Whites. For AIAN and non‐Hispanic White males the prevalence was 10.1%; for females it was 18.2% for AIAN and 13.0 for non‐Hispanic Whites, respectively 6. Whereas 21% (n=131) of the TASP sample had been diagnosed by a doctor or other health professional with asthma; the crude prevalence of asthma was 14.3% for males and 25.3% for females. The prevalence of asthma in children under the age of 18 living in a survey participant’s home was 21%. Of children who had been diagnosed with asthma, 79% still had asthma. In the past 12 months, 71% of children diagnosed with asthma had symptoms, taken medication, or seen a doctor for their asthma. Educational efforts on controlling mold in the home would be beneficial to this community, as women who had seen and smelled mold in their home were more likely to have asthma than women who had not seen or smelled mold. Mold is a known trigger for aggravating asthma and asthmatic conditions. Many participants expressed gratitude after completing the survey, explaining it had “opened their eyes” to potential asthma triggers in their home. Educational efforts tailored to the AIAN community in California would likely be welcome. Of the TASP population, 28% lived on a reservation or Rancheria and 51% were renters. Because tribal housing policies can differ from more common housing policies, and because the majority of the community does not own their home, there is likely little control over housing structure and repair work. Thus, culturally competent educational efforts on having an asthma‐friendly home would assist the AIAN community in reducing and preventing home asthma triggers. Cost of Asthma in California The cost of asthma to the AIAN population in California cannot be accurately estimated with the TASP survey, but days of productivity lost in the workplace as well as potentially preventable hospitalization stays can help direct future analysis for the true cost of asthma. According to CHIS (2007), 29% of AIAN in California missed at least 1 day of school due to asthma. In the TASP population who had been told by a doctor or other health professional that they had asthma (n=131), 17% had missed at least 1 day of school or work in the past 12 months due to asthma. Almost 23% had visited the emergency room at least once in the past 12 months for asthma‐related reasons. In 2003, Korenbrot and colleagues found that hospitalizations and avoidable hospitalization rates are higher for the AIAN population served by California Tribal Health Programs than the non‐Indian general population; age‐adjusted relative risk hospitalization ratios were higher for men (RR: 1.72, 95% confidence interval (CI): 1.40, 2.12) and 52% higher for women (RR: 1.52, CI: 1.36, 1.92), and the comparable ratios for avoidable hospitalizations were 136% higher for men (RR: 2.36, CI 1.52, 3.29) and 106% higher for women (RR: 2.06, CI: 1.32, 3.50) 20. Furthermore, in the TASP population 72% of those with doctor‐diagnosed asthma reported that their usual activities had been limited due to asthma in the past 12 months. The loss of productivity in the workplace as well as preventable hospitalizations due to asthma deserve further research to accurately estimate the true “cost” of asthma in the California AIAN population. Future Research While the TASP study had participants throughout California in several counties with high AIAN populations, and included both rural and urban AIAN, the study may not be representative of the exceptionally diverse AIAN population in California. More research is needed on asthma status, asthma conditions, and housing conditions for AIAN. Due to time limitations and funding constraints, TASP was not able to conduct face‐to‐face interviews. Face‐to‐face interviews can help increase the number of questions answered correctly, reduce errors associated with skip‐patterns, and increase the overall quality of survey responses received. Future surveys at tribal events would benefit from face‐to‐face, rather than self‐administered surveys. Anecdotally, many participants commented after completing the survey about barriers they faced in receiving effective asthma services, including methods for controlling their asthma symptoms. Many participants, also,

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commented on tribal policies or policies in the house or apartment they faced that were beyond their control, and feared could aggravate asthma or allergies (such as cigarette smoke from other apartments and trash being burnt near windows). Conducting focus groups that can help identify perceived and/or actual barriers in controlling asthma symptoms, receiving effective medical care, and improving housing conditions and/or housing policies could help inform future interventions on asthma and housing conditions.

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REFERENCES

1. Akinbami L. Asthma Prevalence, Health Care Use and Mortality: United States, 2003‐05. Centers for Disease Control and Prevention, National Center for Health Statistics, 2006.

2. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics‐‐2002. J Allergy Clin Immunol 2002;110(5 Suppl):S141‐219.

3. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, Gibson P, Ohta K, O'Byrne P, Pedersen SE, Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008;31(1):143‐78.

4. Akinbami L. The state of childhood asthma, United States, 1980‐2005. Adv Data 2006(381):1‐24. 5. Milet M TS, Eatherton M. The Burden of Asthma in California: A Surveillance Report. In: California

Department of Health Services EHIB, ed, 2007. 6. Patricia M. Barnes MAPFAaEP‐G, Ph.D. . Health Characteristics of the American Indian or Alaska Native

Adult Population: United States, 2004 ‐ 2008. In: Reports. NHS, ed. 20 ed, March 9, 2010. 7. Brim SN, Rudd RA, Funk RH, Callahan DB. Asthma prevalence among US children in underrepresented

minority populations: American Indian/Alaska Native, Chinese, Filipino, and Asian Indian. Pediatrics 2008;122(1):e217‐22.

8. Liu LL, Stout JW, Sullivan M, Solet D, Shay DK, Grossman DC. Asthma and bronchiolitis hospitalizations among American Indian children. Arch Pediatr Adolesc Med 2000;154(10):991‐6.

9. Meng YY, Babey SH, Hastert TA, Brown ER. California's racial and ethnic minorities more adversely affected by asthma. Policy Brief UCLA Cent Health Policy Res 2007(PB2007‐3):1‐7.

10. Weiss KB, Gergen PJ, Wagener DK. Breathing better or wheezing worse? The changing epidemiology of asthma morbidity and mortality. Annu Rev Public Health 1993;14:491‐513.

11. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma‐‐United States, 1980‐1999. MMWR Surveill Summ 2002;51(1):1‐13.

12. Moorman JE, Rudd RA, Johnson CA, King M, Minor P, Bailey C, Scalia MR, Akinbami LJ. National surveillance for asthma‐‐United States, 1980‐2004. MMWR Surveill Summ 2007;56(8):1‐54.

13. Frisk ML, Stridh G, Ivarsson AB, Kamwendo K. Can a housing environmental index establish associations between indoor risk indicators and clinical tests in persons with asthma? Int J Environ Health Res 2009:1‐16.

14. Salo PM, Arbes SJ, Jr., Crockett PW, Thorne PS, Cohn RD, Zeldin DC. Exposure to multiple indoor allergens in US homes and its relationship to asthma. J Allergy Clin Immunol 2008;121(3):678‐684 e2.

15. Leaderer BP, Belanger K, Triche E, Holford T, Gold DR, Kim Y, Jankun T, Ren P, McSharry Je JE, Platts‐Mills TA, Chapman MD, Bracken MB. Dust mite, cockroach, cat, and dog allergen concentrations in homes of asthmatic children in the northeastern United States: impact of socioeconomic factors and population density. Environ Health Perspect 2002;110(4):419‐25.

16. Assessment of American Indian Housing Needs and Programs: Final Report. US Department of Housing and Urban Development, May 1996.

17. Bureau USC. American Fact Finder. Summary File 2, 2000. 18. Congress US. Federal Register. Vol. 74;40218. 19. Surdu S, Montoya LD, Tarbell A, Carpenter DO. Childhood asthma and indoor allergens in Native

Americans in New York. Environ Health 2006;5:22. 20. Korenbrot CC, Ehlers S, Crouch JA. Disparities in hospitalizations of rural American Indians. Med Care

2003;41(5):626‐36.

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APPENDIX A: SURVEY QUESTION SOURCES

Border Asthma & Allergies Study (BASTA). Questionnaire for 7th and 8th Graders. California Department of Public Health: Environmental Health Investigations Branch. http://www.ehib.org/project.jsp?project_key=BAST01 National Survey of Lead Hazards and Allergens in Housing (NSLHAH). US Department of Housing and Urban Development & National Institute of Environmental Health Sciences. http://www.niehs.nih.gov/health/topics/conditions/asthma/studies/riskassess/nslah.cfm Behavioral Risk Factor Surveillance System Questionnaire (BRFSS): 2007. Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/brfss/ Adult Asthma Call‐Back Survey. Adult Questionnaire: 2008. Behavioral Risk Factor Surveillance System Questionnaire (BRFSS). Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/asthma/survey/brfss.html Northwest Tribal Behavioral Risk Factor Surveillance System (BRFSS) Project Questionnaire. Northwest Portland Area Indian Health Board. 2001. http://www.npaihb.org/programs/project/2001_northwest_tribal_brfss_project/ American Indian Adult Tobacco Survey (AI‐ATS). Center for Disease Control and Prevention (CDC). http://www.cdc.gov/tobacco/data_statistics/surveys/american_indian/index.htm Childhood asthma and indoor allergens in Native Americans in New York. Simona Surdu, Lupita D Montoya, Alice Tarbell, and David O Carpenter. Environmental Health: A Global Access Science Source 2006, 5:22. http://www.ehjournal.net/content/5/1/22

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APPENDIX B: THE BORDER ASTHMA AND ALLERGIES STUDY (BASTA)

Environmental Health Investigations Branch • California Department of Public Health

Summary of FindingsNovember 2009

BackgroundImperial County has the highest rate of childhood asthma hospital admissions in Califor-nia. In 2003, children 0 –14 years old were admitted to the hospital because of asthma more than three times the state average. Nearly 85% of these hospital admissions oc-curred among Latino children.

In May 2005, the California Department of Public Health conducted a health survey in Imperial County called the Border Asthma and Allergies study or BASTA. The purpose of the survey was to:

determine the amount of asthma and asthma symptoms in young teenagers, and• examine family and environmental factors that might be related to asthma.•

ParticipantsIn total, 3,224 students from 10 schools completed the survey. Students were from 7th and 8th grade classrooms, and most were 13 or 14 years old. The students attended large and small schools in cities and in rural areas.

About 76% of the students who took the survey were of Mexican heritage and described themselves as Mexican or Mexican-American. Another 11% called themselves “Other Latino,” specifically Black Latino, Mexican Indian, or other. Almost 7% said that they were White, and 6% said that they were either Black, Asian or another race. Students reported that they spoke Spanish (42%), English (34%), or both languages (23%) at home.

Asthma ResultsOf all the students surveyed, about one in five (20%) had been diagnosed with asthma at some point in their life. Of these students, one in eight (12.5%) said that they had symptoms of asthma, such as wheezing, chest tightness, or repeated coughing, at some point during the past year.

When compared with children of all races in California and the United States at that time, BASTA participants had a higher percentage of asthma.

The National Survey looked at young people ages 5–14, whereas BASTA students were 12–15 years old. These numbers are not exactly comparable because we would expect to see a higher percentage of asthma in BASTA students than in younger children who were included in the National Survey. An exact national comparison group for BASTA students is not available.

1 California Health Interview Survey (CHIS), 20052 National Health Interview Survey (NHIS), 2005* Note: NHIS asthma percentage is for ages 5–14, whereas CHIS and BASTA are for ages 12–15.

2005 Study Groups Children of All Races

Percent with asthma

BASTA Survey 20.2%

California Survey1 19.3%

National Survey2* 13.7%

Border Asthma & Allergies Study

BASTA

Asthma among Students of Mexican HeritageAlmost 1 in 5 (18.6%) students of Mexican heritage had asthma in the BASTA survey.

Asthma in Students of All Racial GroupsStudents of all racial groups in BASTA had higher percentages of asthma than compared with the rest of Cali-fornia or the United States. However, it’s important to note that, except for those of Mexican heritage, these percentages are based on very small numbers of students and therefore could be different if measured in a larger population. This table shows the percentages of students in the BASTA survey with asthma broken down by race or ethnicity.

SchoolsOf the ten schools participating in BASTA, most had relatively large percentages of students who had ever had asthma among the 7th and 8th graders who took the survey. Some schools had per-centages as high as 25% (1 in 4 students). We are providing these percentages because local com-munity groups and schools have expressed an interest in this infor-mation. However, these numbers represent a snapshot in time of the asthma percentages among young teenagers who took this survey, and these numbers may be different now. More importantly, for the smaller schools, these numbers may be less accurate. We have much more confidence in the results of the overall BASTA survey, which is based on responses of thousands of students from all of the schools. Nevertheless, these findings highlight the need for more school-based asthma programs in Imperial County.

Allergies About 57% of the students reported allergy-related conditions other then asthma in the BASTA survey. These included runny nose without a cold, symptoms of “hay fever” (such as stuffy or runny nose, and itchy or watery eyes), or an itchy rash and eczema. More than

2005 Study Groups Children of Mexican Heritage

Percent with asthma

BASTA Survey 18.6%

California Survey1 14.6%

National Survey2* 12.1%

Race/Ethnicity of BASTA Students

Percent with asthma

White 34%

Asian, Black, Other 22.2%

Other Latino 21.7%

Mexican Heritage 18.6%

School

Number of students

taking surveyPercent with

asthmaBarbara Worth 700 25.2%

Frank Wright 220 21.2%

Heber 148 16.1%

Holtville 216 18.0%

Kennedy 462 12.4%

Meadows 106 23.9%

San Pasqual 85 13.7%

Westmorland 91 23.4%

William Moreno 279 17.4%

Wilson 917 21.8%

1 in 3 (34%) of the students reported that they had been diagnosed with allergies at some point in their lives by a doctor. Based on BASTA findings, children in Imperial Valley may suffer from a wide range of allergies. In addition, among children who have both allergies and asthma, their allergies can make asthma worse.

Breathing Problems in Students without AsthmaA large number of BASTA stu-dents who had never been di-agnosed with asthma said that they had symptoms similar to those due to asthma in the year before the BASTA survey. Though some breathing problems, such as wheezing, are common in childhood, it is possible that a number of children in Impe-rial County have undiagnosed or untreated asthma. Based on the BASTA survey, the percentage of children who might have un-diagnosed asthma could be as low as 2% or as high as 23%, de-pending on how many asthma symptoms were counted. The following table shows the types and percentages of asthma-like symptoms reported by students who did not have a doctor’s diagnosis of asthma.

These findings suggest that there may be a need for more widespread screening pro-grams to detect asthma in this age group and possibly others.

Family and EnvironmentBased on the BASTA findings, family and personal health played a large role in whether a student was likely to have asthma. Students were more likely to have asthma if they had:

a history of allergies or bronchitis;• a runny nose without a cold;• a parent or family member with asthma.•

Free-time activities also influenced who was likely to have asthma. Students were more likely to have asthma if they:

spent three hours or more watching television on the weekends; and if• they spent six hours or more using the computer on the weekends. •

The location and condition of students’ homes were related to whether a child reported having had asthma. Children were more likely to have asthma if they lived in:

houses or apartments that had rats; or• homes located near open and dusty areas.•

Symptoms of asthma in last year among students without asthma

Percent with Symptoms*

Wheeze without a cold or flu AND Wheeze that interrupts sleep 2%

Wheeze without a cold or flu 6%

Wheeze 11%

Dry cough at night without a cold or chest infection 11%

In the last 12 months, any of the following: (i) wheeze, (ii) dry cough at night without cold or

flu, or (iii) repeated dry cough for more

than three weeks. 23%

* percentage based on 2,650 students who had not been diagnosed with asthma by a doctor or nurse.

Students of Mexican HeritageAmong students of Mexican heritage, those who ate more fruit had a lower risk of wheeze.

Students who only spoke Spanish at home had the lowest risk of asthma. The risk of having asthma increased in proportion to the amount of English spoken at home.

Eating fruit and speaking Spanish at home indicate that diet, as well as family or cultural influences, may play a role in asthma.

ConclusionsBASTA findings show that, overall, children in Imperial County are more likely to have asthma at some point in their lives than most other children in California.

Students in the BASTA study had:Higher percentages of asthma than • students in other parts of California;Higher percentages of asthma than a • national comparison group.

BASTA students of Mexican heritage had higher percentages of asthma than children of Mexican heritage in California and Na-tional Health Interview Surveys.

There are children in Imperial County with asthma-like symptoms who have never been diagnosed by a doctor as having asthma. Depending on the number of symptoms counted, the number of children who have undiagnosed (and therefore untreated) asthma could be relatively small or quite high.

Asthma in Imperial County 2009In the four years since the BASTA survey was conducted, children in Imperial County are still three times more likely to be admitted to the hospital for asthma than in the rest of the State. In proportion to its population size, Imperial County has the highest number of asthma-related emergency room visits for children ages 5–17; the age range that includes BASTA participants. These more recent findings lead us to believe that asthma remains a major health problem for young people in Imperial County.

DedicationThe Border Asthma and Allergies Study (BASTA) wishes to dedicate this community report to the memory of Marie Dugan Delgado. Marie was a 16-year old sophomore at Southwest High School in Imperial County who passed away on May 29, 2009, as the result of an asthma attack.

What is Asthma?*Asthma is a disease that affects the lungs. It is one of the most common long-term diseases in children, but adults have asthma too. People with asthma have it all the time, but will have asthma at-tacks only when something like a cold or smoke irritates their lungs. Asthma can-not be cured, but it can be controlled.

Asthma Symptoms and SignsRep• eated episodes of wheezing or whistling in the chest

Difficulty breathing•

Chest tightness•

Repeated coughing, especially at • night or in the early morning

Approximately 20 million Americans have asthma. The dramatic increase in the number of asthma cases in the last 30 years suggests that environmental factors are at the root of the problem.

* from Asthma Basic Information www.cdc.gov/asthma/faqs.htm

http://www.cdc.gov/asthma/faqs.htm

http://www.cdc.gov/asthma/faqs.htm

Page | 64

APPENDIX C: SURVEY INSTRUMENT

Page | 65

Date: ________ / ________ / ________ Location: _________________________

CTEC SURVEY OF ASTHMA & ALLERGENS IN HOUSING QUESTIONNAIRE The California Tribal Epidemiology Center is distributing a survey to look at how housing conditions affect asthma in American Indians and Alaska Natives. Eligibility criteria: i. Are you American Indian or Alaska Native? 1 YES……………CONTINUE

2 NO ……………We appreciate your willingness to be a part of this survey, but for the study we need American Indian/Alaska Native participants. Thank you very much.

ii. Are you at least 18 years of age? 1 YES……………CONTINUE

2 NO ………………We appreciate your willingness to be a part of this survey, but for the study we need to talk to participants over the age of 18. Thank you very much.

iii. Have you taken the Tribal Asthma Survey, or received a $15 gift card from the California Tribal Epidemiology Center, in the past 12 months?

1 YES ……………… We appreciate your willingness to be a part of this survey, but we can only have each participant take the survey one time. Thank you very much.

2 NO ………………CONTINUE

Before you being the survey, please make sure you have read and signed the informed consent form which explains the study in detail and gives us permission to collect

information from you. The administrator will go over each item of the form with you. You will be given a copy of the informed consent to keep.

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This survey begins with some questions about your home. 1. Which best describes the building you live in? (CHECK ONLY ONE)

1 A MOBILE HOME OR TRAILER 2 A ONE-FAMILY HOUSE (NOT CONNECTED TO ANOTHER HOUSE)

3 A DUPLEX (A HOUSE CONNECTED TO ONE OR MORE HOUSES) 4 A TOWNHOUSE (A HOUSE SHARING AN OUTER WALL WITH ONE OR

MORE OTHER HOUSES) 5 A BUILDING WITH 3 OR 4 APARTMENTS/CONDOS 6 A BUILDING WITH 5 OR MORE APARTMENTS/CONDOS 7 A VAN OR OTHER VEHICLE…… (SKIP TO QUESTION 43) 8 NO PERMANENT HOME…… (SKIP TO QUESTION 43) 9 OTHER (SPECIFY)_________________________________________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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2. What year was your home built?

|___|___|___|___| YEAR OF CONSTRUCTION

888 I DON’T KNOW/UNSURE 999 I PREFER NOT TO ANSWER

3. If you are unsure what year your home was built, which category of years do you think most closely matches when the building was built?

1 □1949 OR EARLIER

2 □ BETWEEN 1950 AND 1977

3 □1978 - PRESENT

888 □ I DON’T KNOW

999 □ I PREFER NOT TO ANSWER

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4. How long have you lived in this home?

|___|___|YEARS |___|___|MONTHS |___|___|WEEKS 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

5. How many other people live in this home, besides yourself?

|___|___|(NUMBER OF PEOPLE)

888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

6. Is your home on a reservation, Rancheria, or other form of tribal land?

1 YES 2 NO 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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7. Do you own or rent your home?

1 OWN………SKIP TO QUESTION 10 2 RENT

3 OTHER: _____________________________ 4 RENT-TO-OWN 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

8. Is your home or apartment owned by a public housing authority or the government?

1 YES……SKIP TO QUESTION 11 2 NO 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

9. Are you currently receiving public housing subsidies (for example: Section 8 Rental Vouchers)?


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10. Have you ever received funds from your tribe for housing? (for example: Native American Housing Assistance, HUD Indian Community Development Block Grants, BIA Home Improvement Program, etc.)


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The next series of questions are to collect information that can affect the levels of allergens in your home. 11. Is the home you live in now located on or within a quarter mile of a farm, ranch or agricultural field?


12. Is there an open dusty area near your home? (For this question, “near” means within 200 feet, or 2 basketball courts.)


13. Is there a rail yard near your home? (For this question, “rail yard” could be an area where trains are stored, where trains pick up and/or drop off cargo, and “near” means within 200 feet, or 2 basketball courts.)


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14. How close is your home to a street with heavy traffic? (For this question, “street with heavy traffic” could be a freeway, highway, major intersection, or a street with lots of cars, buses and trucks). (For reference purposes, a basketball court is 100 feet long).

1 RIGHT IN FRONT, BEHIND, OR BESIDE MY HOME. 2 LESS THAN 100 FEET (LESS THAN 1 BASKETBALL COURT LENGTH) 3 100-300 FEET (1 TO 3 BASKETBALL COURT LENGTHS) 4 MORE THAN 300 FEET (MORE THAN 3 BASKETBALL COURT LENGTHS)


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15. When it’s cold, how do you heat your home? (CHECK ALL THAT APPLY)

1 GAS OR ELECTRIC CENTRAL HEATING

2 SPACE HEATER(S)

3 WOOD BURNING STOVE/FIREPLACE 4 NO SOURCE OF HEAT

5 OTHER (SPECIFY)____________________________


16. During the past 12 months, on how many days have you used a wood or coal stove, wood-burning fireplace, or kerosene heater inside your home?

|___|___|___| (NUMBER OF DAYS) 666 DOES NOT HAVE 777 NO DAYS (ZERO) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

17. Is gas used for cooking?


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18. Is an exhaust fan that vents to the outside used regularly when cooking in your kitchen?


19. In your bathroom, do you regularly use an exhaust fan that vents to the outside? (If you have more than one bathroom, think about the bathroom you use most frequently for showering and bathing).


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20. An air cleaner or air purifier can filter out pollutants like dust, pollen, mold and chemicals. It can be attached to the furnace or free standing. It is not, however, the same as a normal furnace filter. Is an air cleaner or purifier regularly used inside your home?

1 YES 2 NO……SKIP TO QUESTION 23 888 I DON’T KNOW……SKIP TO QUESTION 23

999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 23

21. What kind of air cleaner or air purifier do you use?

1 OZONE GENERATING / OZONATOR 2 IONIZING / IONIC CLEANER / ELECTROSTATIC CLEANER 3 HEPA FILTER CLEANER (HIGH EFFICIENCY PARTICULATE AIR) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

22. How often do you change or wash the air filter(s)? Is it…

1 ONCE A WEEK 2 EVERY 1 – 4 MONTHS 3 MORE THAN 4 MONTHS, UP TO 12 MONTHS 4 MORE THAN 12 MONTHS 5 NEVER 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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23. Has there ever been water or dampness in your home from broken pipes, leaks, heavy rain, or floods?


24. In the past 30 days, did your home have mold on an area greater than the size of a dollar bill? Do not include mold on food.


25. In the past 30 days, has anyone seen or smelled mold or a musty odor inside your home? Do not include mold on food.


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26. A dehumidifier is a small, portable appliance which removes moisture from the air. Is a dehumidifier regularly used to reduce moisture inside your home?


27. In the past six months have you had any of the following pets living inside your home? (CHECK ALL THAT APPLY)

1 DOG(S) 2 CAT(S) 3 BIRD(S) OR CHICKEN(S) 4 PET MICE OR RATS 5 GERBILS, HAMSTERS OR RABBITS

6 OTHER PET WITH FUR OR FEATHERS (SPECIFY)___________________ 7 NONE OF THE ABOVE 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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28. Do you use a mattress cover that is made especially for controlling dust mites?


29. Do you use a pillow cover that is made especially for controlling dust mites?


30. When was the carpet/rug last vacuumed?

1 1 TO 6 DAYS AGO 2 7 DAYS TO 2 WEEKS AGO 3 MORE THAN 2 WEEKS TO 1 MONTH AGO 4 MORE THAN 1 MONTH TO 2 MONTHS AGO 5 MORE THAN 2 MONTHS AGO 6 DOES NOT HAVE CARPETS/RUGS…….. SKIP TO QUESTION 32 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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31. When was the last time the carpet/rug was shampooed or steamed cleaned?

1 WITHIN THE LAST MONTH 2 MORE THAN 1 MONTH TO 6 MONTHS AGO 3 MORE THAN 6 MONTHS TO 12 MONTHS AGO 4 MORE THAN 1 YEAR TO 2 YEARS AGO 5 MORE THAN 2 YEARS AGO


32. When was the last time upholstered sofas or chairs were vacuumed?

1 1 TO 6 DAYS AGO 2 7 DAYS TO 2 WEEKS AGO 3 MORE THAN 2 WEEKS TO 1 MONTH AGO 4 MORE THAN 1 MONTH TO 2 MONTHS AGO 5 MORE THAN 2 MONTHS AGO 6 DOES NOT OWN ANY UPHOLSTERED FURNITURE 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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33. When was the bedding last washed?

|___|___| (NUMBER OF DAYS) |___|___| (NUMBER OF WEEKS) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

34. Are your sheets and pillowcases washed in cold, warm, or hot water?

1 COLD 2 WARM 3 HOT

4 IT VARIES 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

35. Which of the following do you use to clean your home? (CHECK ALL THAT APPLY)

1 BLEACH OR BLEACH PRODUCTS 2 DISINFECTANT SPRAYS, WIPES OR SOLUTIONS 3 AIR FRESHENERS 4 “GREEN” OR NON-TOXIC PRODUCTS 5 OTHER TYPES OF CLEANING PRODUCTS (SPECIFY)_______________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 81

Studies have shown that cockroaches may be a cause of asthma. Cockroach droppings and carcasses can also cause symptoms of asthma. 36. In the past 30 days, has anyone seen a cockroach inside your home?


37. In the past 30 days, has anyone seen mice or rats inside your home? Do not include mice or rats kept as pets.


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38. During the past 12 months, on how many days were pesticides, sprays, or chemicals applied inside your home to kill bugs, mice, or other pests? Include use by yourself, others, and professional exterminators. (INCLUDE PESTICIDE POWDERS, BUT DO NOT INCLUDE PEST TRAPS, PEST STRIPS, OR HERBAL TREATMENTS).

|___|___|___| (NUMBER OF DAYS) 777 NONE 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

39. During the past 12 months, on how many days were pesticides or chemicals applied in your yard or garden to kill plant, animal, or insect pests. Include use by yourself, others, and lawn care services professionals. (DO NOT INCLUDE LIME OR FERTILIZER IF NO WEED OR BUG KILLER USED).

|___|___|___| (NUMBER OF DAYS) 666 DO NOT HAVE A GARDEN/YARD

777 NONE 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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40. Is trash burned by you or others near your home? 1 YES 2 NO……SKIP TO QUESTION 43 888 I DON’T KNOW……SKIP TO QUESTION 43


41. Approximately how far away from the home is the area where trash is burnt?

|___|___|___| (DISTANCE IN FEET) |___|___|___| (DISTANCE IN MILES) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

42. Approximately how often is the trash burnt?

1 EVERY DAY 2 A FEW DAYS PER WEEK 3 ONCE A WEEK 4 ONCE EVERY TWO WEEKS 5 ONCE A MONTH 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 84

I am now going to ask you some questions about asthma and allergies. 43. Have you ever been told by a doctor or other health professional that you have asthma?

1 YES 2 NO……SKIP TO QUESTION 58 888 I DON’T KNOW……SKIP TO QUESTION 58 999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 58

44. How old were you when you were first told by a doctor or other health professional that you had asthma?

|___|___|(AGE IN YEARS)


45. Do you still have asthma?


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46. Was your asthma caused or made worse by chemicals, smoke, fumes, or dust in any job you ever had?


47. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?

|___|___|(NUMBER OF VISITS)


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48. How long has it been since you last took asthma medication? 1 NEVER

2 LESS THAN ONE DAY AGO

3 1-6 DAYS AGO

4 1 WEEK TO LESS THAN 3 MONTHS AGO

5 3 MONTHS TO LESS THAN 1 YEAR AGO

6 1 YEAR TO LESS THAN 3 YEARS AGO

7 3 TO LESS THAN 5 YEARS AGO

8 MORE THAN 5 YEARS AGO


Page | 87

49. Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when you do not have a cold or respiratory infection. How long has it been since you last had any symptoms of asthma?

1 NEVER……SKIP TO QUESTION 57

2 LESS THAN ONE DAY AGO

3 1-6 DAYS AGO

4 1 WEEK TO LESS THAN 3 MONTHS AGO

5 3 MONTHS TO LESS THAN 1 YEAR AGO ……SKIP TO QUESTION 53

6 1 YEAR TO LESS THAN 3 YEARS AGO……SKIP TO QUESTION 57

7 3 TO LESS THAN 5 YEARS AGO……SKIP TO QUESTION 57

8 MORE THAN 5 YEARS AGO…….SKIP TO QUESTION 57


50. During the past 30 days, on how many days did you have any symptoms of asthma?

|___|___|(NUMBER OF DAYS)


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51. In the past 30 days, on how many days did symptoms of asthma make it difficult for you to stay asleep?

|___|___| (NUMBER OF DAYS)

777 NONE


52. During the past 3 months, how many asthma episodes or attacks have you had?

|___|___|___| (NUMBER OF EPISODES/ATTACKS)

777 NONE


53. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?

|___|___|___| (NUMBER OF TIMES)

777 NONE


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54. During the past 12 months, how many different times did you stay in any hospital overnight or longer because of your asthma?

|___|___|___| (NUMBER OF TIMES)

777 NONE


55. During the past 12 months, how many days of work or school did you miss because of your asthma?

|___|___| (NUMBER OF DAYS)

777 NONE


56. During the past 12 months, would you say you limited your usual activities due to asthma not at all, a little, a moderate amount, or a lot?

1 NOT AT ALL

2 A LITTLE 3 A MODERATE AMOUNT 4 A LOT


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57. When you have symptoms of asthma what do you usually do? (CHECK ALL THAT APPLY)

1 TAKE MEDICINE PRESCRIBED BY A DOCTOR (SUCH AS AN INHALER)

2 TAKE NON-PRESCRIPTION MEDICINE (INCLUDING OVER-THE-COUNTER MEDS)

3 GO TO A DOCTOR, A CLINIC, OR A HOSPITAL FOR HELP

4 GO TO A NATIVE HEALER (SUCH AS A MEDICINE MAN)

5 USE TRADITIONAL MEDICINES

6 WAIT UNTIL IT PASSES

7 OTHER: ______________________________________________________


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58. Have you ever been told by a doctor or health professional that you have hay fever or allergic rhinitis?

1 YES

2 NO


59. Have you ever been told by a doctor or health professional that you have eczema or skin allergies?

1 YES

2 NO


60. Have you ever been told by a doctor or health professional that you have chronic obstructive pulmonary disease, also known as COPD?

1 YES

2 NO


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61. Are there any children under the age of 18 living in your house?

1 YES

2 NO……SKIP TO QUESTION 63

888 I DON’T KNOW……SKIP TO QUESTION 63 999 I PREFER NOT TO ANSWER…….SKIP TO QUESTION 63

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62. We would like to know a little more about the children under the age of 18 who live in this home. (REMINDER: IF NO CHILDREN UNDER THE AGE OF 18, SKIP THIS QUESTION).

a. b. c. d. e. f. g.

Initials Gender Age Race/ Ethnicity (circle all that apply)

Has (name) ever been diagnosed by a doctor or other health professional

with asthma?

Does (name) still have asthma?

In the past 12 months, has (name) had symptoms, taken medication, or seen a health

professional for their asthma?

1

Male

American Indian/Alaska Native Yes Yes Yes

White Black

No No No Asian Native Hawaiian/Pacific Islander

Female

Latino/Hispanic Don’t Know Don’t Know Don’t Know

Other (Specify) Don’t Know

Prefer not to answer Prefer not to answer Prefer not to answer

Prefer not to answer

2

Male


White Black

No No No Asian Native Hawaiian/ Pacific Islander

Female



Prefer not to answer Prefer not to answer Prefer not to answer Prefer not to answer

REF

3

Male


White Black


Female





Page | 94

a. b. c. d. e. f. g.

Initials Gender Age Race/ Ethnicity (circle all that apply)

Has (name) ever been diagnosed by a doctor or other health professional

with asthma?

Does (name) still have asthma?

In the past 12 months, has (name) had symptoms, taken medication, or seen a health

professional for their asthma?

4

Male


White Black


Female





5

Male


White Black


Female



Prefer not to answer Prefer not to answer Prefer not to answer Prefer not to answer

REF

6

Male


White Black


Female





Page | 95

Not including ceremonial or sacred smoking, we want you to think of all the commercial cigarettes you ever smoked in your entire life. 63. Have you smoked at least 100 cigarettes, about 5 packs, in your entire life?

1 YES 2 NO……SKIP TO QUESTION 65 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

64. Not including ceremonial or sacred smoking, do you now smoke cigarettes every day, some days, or not at all?

1 EVERY DAY

2 SOME DAYS

3 NOT AT ALL / NO DAYS


Page | 96

65. During the past 7 days, on how many days were you in the same room with someone who was smoking cigarettes?

1 0 DAYS 2 1 OR 2 DAYS 3 3 OR 4 DAYS 4 5 OR 6 DAYS 5 ALL 7 DAYS 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

66. During the past 7 days, on how many days were you in the same car or other vehicle with someone who was smoking cigarettes?

1 0 DAYS 2 1 OR 2 DAYS 3 3 OR 4 DAYS 4 5 OR 6 DAYS 5 ALL 7 DAYS 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 97

67. Do any of the people who live in your home use any of the following commercial tobacco products inside the home? (CHECK ALL THAT APPLY). (FOR EXAMPLE, MARLBORO, GCP, DRUM, BUGLER, NATURAL AMERICAN SPIRIT, ETC.)

1 COMMERCIAL TOBACCO CIGARETTES 2 COMMERCIAL TOBACCO CIGARS 3 COMMERCIAL TOBACCO PIPES 777 NONE


68. Which statement best describes the rules about smoking inside your home?

1 SMOKING IS NOT ALLOWED ANYWHERE INSIDE YOUR HOME 2 SMOKING IS ALLOWED IN SOME PLACES OR AT SOME TIMES 3 SMOKING IS ALLOWED ANYWHERE INSIDE YOUR HOME 4 THERE ARE NO RULES ABOUT SMOKING INSIDE YOUR HOME 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 98

69. Have you ever experienced second-hand smoke drifting into your home?


70. Do you use tobacco for ceremonial, prayer or traditional reasons?

1 YES 2 NO……SKIP TO QUESTION 74 888 I DON’T KNOW ……SKIP TO QUESTION 74 999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 74

71. When you used tobacco for ceremonial prayer or traditional reasons, what type of tobacco did you use? (CHECK ALL THAT APPLY)

1 NATIVE TOBACCO 2 COMMERCIAL TOBACCO (FOR EXAMPLE, MARLBORO, GCP, DRUM,

BUGLER, NATURAL AMERICAN SPIRIT, ETC.) 3 OTHER (SPECIFY)_________________________________________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 99

72. Have you ever smoked a pipe for ceremonial prayer or traditional reasons? 1 YES 2 NO……SKIP TO QUESTION 74 888 I DON’T KNOW ……SKIP TO QUESTION 74 999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 74

73. When you smoked a pipe for ceremonial prayer or traditional reasons, what type of tobacco did you use? (CHECK ALL THAT APPLY)

1 NATIVE TOBACCO 2 COMMERCIAL TOBACCO (FOR EXAMPLE, MARLBORO, GCP, DRUM,

BUGLER, NATURAL AMERICAN SPIRIT, ETC.) 3 OTHER (SPECIFY)_________________________________________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 100

74. This survey has asked you about issues in your house like mold and second hand smoke. Now we’d like to ask you a little more about how concerned you are about these home environmental issues in terms of your, or your family’s, health. How concerned are you about each of the following issues?

Not At All Concerned

Not Too Concerned

Somewhat Concerned

Very Concerned

Don’t

Kn

ow

Prefer n

ot to an

swer

MOLD OR MOISTURE OUTDOOR AIR POLLUTION (SUCH AS FROM TRAFFIC, AGRICULTURAL PESTICIDES, OR DUST) DRIFTING INTO YOUR HOUSE

OLD CARPETING FUMES FROM NEW FURNITURE, FLOORING OR CARPETING

PESTS, SUCH AS RODENTS OR COCKROACHES

CLEANING CHEMICALS COMMERCIAL TOBACCO SMOKED IN YOUR HOUSE

SECONDHAND SMOKE DRIFTING INTO YOUR HOUSE

OTHER ISSUES NOT MENTIONED ABOVE: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Page | 101

75. Of the issues we just talked about, do you think any of these are health concerns for others in your neighborhood?

1 YES 2 NO……SKIP TO QUESTION 77 888 I DON’T KNOW ……SKIP TO QUESTION 77


76. If yes, which issues? (CHECK ALL THAT APPLY)

1 MOLD OR MOISTURE 2 OUTDOOR AIR POLLUTION (SUCH AS FROM TRAFFIC, AGRICULTURAL

PESTICIDES, OR DUST) DRIFTING INTO YOUR HOUSE 3 OLD CARPETING 4 FUMES FROM NEW FURNITURE, FLOORING OR CARPETING 5 PESTS, SUCH AS RODENTS OR COCKROACHES 6 CLEANING CHEMICALS 7 COMMERCIAL TOBACCO SMOKED IN YOUR HOUSE 8 SECONDHAND SMOKE DRIFTING INTO YOUR HOUSE 9 OTHER HOME ENVIRONMENTAL ISSUES: _______________________________________________________________________________ _______________________________________________________________________________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 102

The next few questions are on your health. 77. Would you say that in general your health is…

1 EXCELLENT

2 VERY GOOD

3 GOOD

4 FAIR

5 POOR


78. Have you ever been told by a doctor that you have diabetes?

1 YES 2 YES, BUT FEMALE TOLD ONLY DURING PREGNANCY

(ALSO KNOW AS GESTATIONAL DIABETES) 3 NO……SKIP TO QUESTION 81 4 NO; PRE/BORDERLINE DIABETES…… SKIP TO QUESTION 81 888 I DON’T KNOW……SKIP TO QUESTION 81 999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 81

Page | 103

79. How old were you when you were told you had diabetes? |___|___|(AGE IN YEARS)


80. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

|___|___|___| (NUMBER OF TIMES) 777 NONE


Page | 104

81. About how much do you weigh without shoes? |___|___|___| (WEIGHT, IN POUNDS)


82. About how tall are you without shoes?

|___|___|___| (HEIGHT, IN FEET AND INCHES)


83. Breastfeeding has been found to possibly reduce the effects of asthma. Were you breast fed as an infant?


Page | 105

84. What is your age?

|___|___|___| (AGE, IN YEARS)


85. What is your sex?

1 MALE 2 FEMALE 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

Page | 106

86. Are you currently employed? (INCLUDE SELF-EMPLOYED WORK AND PART-TIME WORK).

1 YES 2 NO……SKIP TO QUESTION 89 888 I DON’T KNOW ……SKIP TO QUESTION 89 999 I PREFER NOT TO ANSWER……SKIP TO QUESTION 89

87. What is your current occupation? (If you work at more than one job, then only answer with respect to your main job, where you work the most hours)

(fill-in): ________________________________________________________________


88. What kind of business do you work for? That is, what do they do or make?

(fill-in): ________________________________________________________________


Page | 107

89. Is an Indian Health Service (IHS) funded clinic, a Tribal Health Program or an Urban Indian Clinic your usual source of care?


90. What is the highest grade or year of school you completed?

1 NEVER ATTENDED SCHOOL/ONLY KINDERGARTEN 2 GRADES 1 THROUGH 8 (ELEMENTARY) 3 GRADES 9 THROUGH 11 (SOME HIGH SCHOOL) 4 GRADE 12 OR GED (HIGH SCHOOL GRADUATE)

5 SOME COLLEGE, VOC/TECH SCHOOL 6 COLLEGE GRADUATE (4 YEARS COLLEGE OR MORE) 7 MASTERS DEGREE (COLLEGE GRADUATE DEGREE) 8 DOCTORAL DEGREE (PH.D/MD, DOCTORAL GRADUATE DEGREE) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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91. In addition to American Indian or Alaska Native, would you consider yourself to be one or more additional races? (CHECK ALL THAT APPLY)

1 WHITE 2 BLACK OR AFRICAN AMERICAN 3 HISPANIC OR LATINO 4 ASIAN

5 NATIVE HAWAIIAN 6 PACIFIC ISLANDER 7 SOME OTHER GROUP (SPECIFY):____________________________________ 8 NO OTHER RACE; AMERICAN INDIAN/ALASKA NATIVE ONLY


92. What is your tribal affiliation?

(fill-in): ________________________________________________________________


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We asked you to self-identify your race. Now I will ask how other people usually identify your race. 93. How do other people usually classify you? (CHECK ALL THAT APPLY)

1 WHITE 2 BLACK OR AFRICAN AMERICAN 3 HISPANIC OR LATINO 4 ASIAN

5 NATIVE HAWAIIAN 6 PACIFIC ISLANDER 7 AMERICAN INDIAN/ALASKA NATIVE 8 SOME OTHER RACE/ETHNICITY (SPECIFY):__________________________ 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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I am going to ask about your annual household income. This information will be kept confidential. 94. Last year, what was your total household income from all sources?

1 $ 5,000 OR LESS 2 $ 5,001 to $ 10,000 3 $ 10,001 to $ 15,000 4 $ 15,001 to $ 20,000 5 $ 20,001 to $ 30,000 6 $ 30,001 to $ 40,000

7 $ 40,001 to $ 50,000

8 $ 50,001 to $ 60,000 9 $ 60,001 to $ 80,000 10 $ 80,001 to $100,000

11 $ 100,001 TO $ 135,000 12 GREATER THAN $ 135,000 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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95. What state and county do you live in? STATE: |___|___| COUNTY: __________________________________________


96. What is your ZIP Code where you live?

|___|___|___|___|___| (5-DIGIT ZIP CODE OF HOME RESIDENCE) 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

97. What is your ZIP Code where you work?

|___|___|___|___|___| (5-DIGIT ZIP CODE OF WORK ADDRESS) 777 DOES NOT WORK 888 I DON’T KNOW 999 I PREFER NOT TO ANSWER

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THANK YOU! Thank you for taking the time to complete this survey. Your answers will help us to identify housing conditions associated with asthma in the Native community, and to

enhance currently available services and programs.

Please return your survey to the next available administrator to receive your gift card.

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APPENDIX D: INFORMED CONSENT

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California Tribal Epidemiology Center 4400 Auburn Blvd 2nd Floor • Sacramento CA 95841

PH: (800) 274-4288 • (916) 929-9761 [email protected]

Respondent Informed Consent Form

Purpose and Benefits

The California Tribal Epidemiology Center (EpiCenter), through funding from the California Department of

Public Health (CDPH), is conducting a survey on asthma. In the general population, housing conditions are

associated with asthma. We do not have enough information about asthma in American Indian populations, or

the housing conditions that may influence asthma. Our main goals in this study are to learn about how common

asthma is in Indian communities and to identify possible housing conditions associated with asthma. Your

participation will help us to identify housing conditions associated with asthma in the community and to

enhance currently available services and programs.

Procedures

If you decide to be in this study, you will be one of approximately 450 adults (18 years of age or older) in this

study. The interview will take about 30 minutes to complete. The interview will include general demographics,

health related questions pertaining to asthma, and questions on current housing conditions.

Confidentiality

You will not be identified with the information you give because the survey is confidential. No one but the

interviewer will know how you answered questions on the survey. The interviewer has signed a pledge to keep

all information about you confidential and the information will not be shared with anyone besides research

personnel. The information kept in this study will be kept in a secure location. Only project staff will have

access to study data. We will not use your name, or any personal identifiable information, when we report

results of the study. The information we collect from you will be combined with information from other Indian

people to better understand how housing conditions may influence asthma in American Indians.

Risks and Benefits

You may feel uncomfortable with some of the questions we ask on this survey. You can refuse to answer any

questions you are uncomfortable with or skip questions you do not want to answer. You can stop the

interview at any time. The likely benefits to you are minimal, however, the study is designed to benefit the

American Indian community by gaining new knowledge.

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Rights as a Volunteer

Your participation in this asthma survey is voluntary. If you decide not to take part or to stop the interview, you

will not lose any services to which you are otherwise entitled. If you have any questions about this project, you

may ask the person interviewing you, or contact the California Tribal Epidemiology Center Director, Dr. Kristal

Chichlowska, at (800) 274-4288 or [email protected]. All research on human volunteers is

reviewed by a committee that works to protect your rights and welfare. If you have questions or concerns about

your rights as a survey respondent you may contact, anonymously if you wish, the California Rural Indian

Health Board (CRIHB) Compliance Officer at (800) 274-4288 or [email protected].

Respondent Agreement

The California Indian Asthma Survey has been explained to me. I voluntarily agree to participate. I have had an

opportunity for my questions to be answered. I know that I may refuse to participate or to stop the interview at

any time without any consequence. I understand that if I have questions about this study or my rights as a

participant, I may contact Dr. Kristal Chichlowska. I understand that as compensation for my participation and

completion of the survey I will receive $15 for my time and contribution.

_______________________________________ _______________ Respondent (print name) Date _______________________________________ Respondent Signature _______________________________________ _______________ Interviewer (print name) Date _______________________________________ Interviewer Signature Copy: Interviewer Respondent

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APPENDIX E: HEALTH EDUCATION MATERIALS

California Tribal Epidemiology Center (CTEC) 4400 Auburn Blvd 2nd Floor • Sacramento CA 95841

(800) 274-4288 • (916) 929-9761 [email protected]

Guidelines for an Asthma-Friendly Home

• Work with your doctor to develop a written asthma plan for your child that includes your child’s asthma triggers and how to avoid them.

• Never smoke around anyone who has asthma, either inside or outside. • Cover mattresses and pillows with dust-proof (“allergen-impermeable”) zippered covers. Wash sheets and blankets once a week in hot water. • Dust with a damp cloth and vacuum carpet and fabric-covered furniture on a regular basis. • Wash and dry hard surfaces, like tabletops, to prevent and remove mold. Replace moldy drywall, ceiling tiles and carpet.

• To avoid having cockroaches don’t leave food or garbage out. Clean up messes and spills and store food in

airtight containers. • Instead of using bug spray, control bugs by using bait or traps. If you have to use a spray, make sure to get some

fresh air into the room and keep anyone with asthma out of that room for several hours after spraying. • Keep pets outside if you can. • To avoid asthma triggers like mold, cockroaches, and dust mites, use

exhaust fans, or open windows when cooking and showering. Fix leaky plumbing or other unwanted sources of water.

• Keep a scent-free home. Perfumes, scented lotions, hair products and

room deodorizers may smell good, but are not good for people with asthma.

• Watch for the Air Quality Index (AQI) in your newspaper or during the local weather report. When AQI reports unhealthy levels, limit outdoor activities.

California Tribal Epidemiology Center (CTEC) 4400 Auburn Blvd 2nd Floor • Sacramento CA 95841

(800) 274-4288 • (916) 929-9761 [email protected]

Myths About Asthma Are asthma medicines addictive? No. The medicines used for asthma are not addictive. Be sure that medications are taken as directed and let a doctor know if there are any problems in taking the medicine. Are inhaled steroids, when used as long-term control medicine, dangerous? The inhaled steroid medicines used as long-term controllers to treat asthma are safe and effective. It is important that inhaled steroid medicine is taken exactly as prescribed by a doctor. The steroids used for medicine are NOT the same as the unsafe steroids some athletes take to build muscle. Do asthma attacks usually sneak up on you? Not usually. The body sends cues called “early warning signs” such as watery eyes, itchy skin or scratchy throat that alert your body that asthma symptoms such as coughing or chest tightness may soon occur or that you are near an asthma trigger. Is asthma serious or is it all in your head? Asthma attacks ARE dangerous. In fact, children with asthma have died from asthma attacks. This is why it is so important that children with asthma and school personnel know what the early warning signs are and know what to do in an emergency. Does having asthma mean students can’t do what their friends can do? No. Properly managed asthma means that children can do everything their friends can do, including play sports, go on field trips or play a musical instrument. Is it to be expected that that children will wake up in the night because they have asthma? No. Sleeping through the night is a sign of properly managed asthma. If a child wakes up in the night because of asthma their asthma in not well-controlled. Make sure the room is cleared of triggers and talk to a doctor about adjusting medication. Since we don’t now what causes asthma, why worry about exposure to asthma triggers? While we don’t know what causes asthma in children, we do know that reducing asthma triggers in the environment, such as exposure to smoke and to strongly scented products, can prevent asthma attacks. Does asthma or asthma medicine keep children from growing? No. Asthma or asthma medications do not keep a child from growing. Studies show that low to medium dose of inhaled corticosteriods (used as long-term control medicine) can potentially decrease growth rate but this effect is not permanent, does not progress, and can be reversible. The potentially small risk of delayed growth is well balanced by the effectiveness of these medications. Will an air cleaning device help remove indoor asthma triggers in the classroom or at home? If you are considering an air-cleaning device, do your homework before investing by visiting http://www.epa.gov/iaq/pubs/residair.html. Your first line of defense is to reduce indoor asthma triggers and to provide proper ventilation.

� Do not allow smoking in your home, car, or around you.

� If you smoke, ask your health care provider for ways to help you quit.Ask family members to quit, too.

� Ask your health care provider for a referral to a quit smoking program, or call the US Network of Quitlines: 800-QUIT-NOW (800-784-8669).

� Wash your hands often. � Don't touch your eyes, nose, or mouth. � Get a flu shot every year, preferably in the fall. � Avoid contact with people who have colds.

� Get special dust mite-proof covers for your pillows and mattresses.� Wash sheets and blankets in hot water every week.� Wash stuffed animals frequently and dry completely.� Avoid having carpeting, if you can.� Vacuum carpet weekly with a HEPA vacuum cleaner.

� Try to keep your windows closed during pollen season and when mold counts are high.

� Plan to do indoor activities on high pollen days.� Ask your health care provider about taking medicine during allergy season. � Get daily air quality forecasts at www.airnow.gov

� Keep pets with fur or feathers out of your home.

� If you can’t keep a pet outdoors, then keep the pet out of yourbedroom, and keep the bedroom door closed.

� Keep pets off upholstered furniture and away from stuffed toys. � Wash your hands after petting or playing with pets.

� Do not leave food or garbage uncovered.� Clean up spills and food crumbs right away.� Store food in airtight containers. � Store cooking grease in the refrigerator.� Keep food out of the bedroom.

� Fix leaking faucets, pipes, or other sources of water.� Clean moldy surfaces with hot water and soap.� Use a dehumidifier in the basement if it is damp and smelly.

� Avoid strong odors and sprays, like perfume, powders, hair spray,paints, incense, cleaning products, candles, and new carpeting.

� Avoid inhaling smoke from burning wood.

� Take your rescue medicine before sports or exercise to prevent symptoms if directed by your health care provider.

� Warm up / cool down for 5-10 minutes before and after sports or exercise.

� Cover your nose and mouth with a scarf when it gets cold.� Sometimes laughing or crying can be a trigger.� Some medicines and foods can trigger asthma.

Cigarette SmokeTobacco smoke can make asthma worse.

Colds, Flu, BronchitisWhen you’re sick, your asthma

is more likely to flare up.

Dust MitesThese tiny bugs live in cloth, carpet, and bedding

and are too small to see with the naked eye.

AnimalsSome people are allergic to skin flakes (dander),

urine, or saliva from animals and birds.

Mice, Rats, and Cockroaches

Some people are allergic to the droppings from these pests.

Indoor MoldThis can be a trigger if your home has high moisture.

Wood Smoke, Strong Odors,and Sprays

These can reduce air quality and irritate airways.

Pollen & Outdoor Air Pollution

Some people are allergic to molds or pollen from trees, grass, and weeds.

Asthma TriggersTriggers are things that make your asthma worse. Some triggers are thingsyou are allergic to and some just irritate your airways. You can reduce howoften your asthma flares up by reducing exposure to your triggers.

Exercise or SportsThese can trigger an asthma attack for some people.

Other TriggersCold air, changes in weather, and strong emotions

can set off an asthma attack!

2009, Minnesota Department of Health, www.health.state.mn.us/asthma or www.asthma-IAAP.com

Triggers What you can do to reduce your triggers

RIBAL ASTHMA SURVEY PROJECT (TASP) FINAL EPORT · AIAN children are 1.82 times more likely to have asthma than White children (95% confidence interval [CI]: 1.33, 2.49) 7. AIAN children

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